- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.64 / $143.52 / $195.71
| Professional | | $100.64 | $143.52 | $195.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.76 / $50.65 / $76.72
| Facility | | $34.76 | $50.65 | $76.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $54.00 / $60.00
| Professional | | $53.00 | $54.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.70 / $83.30 / $112.40
| Professional | | $76.70 | $83.30 | $112.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $160.44
| Facility | | $90.00 | $90.00 | $160.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.79 / $199.08 / $199.08
| Professional | | $155.79 | $199.08 | $199.08 |