- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $616.60
| Professional | | $100.00 | $120.23 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $120.23
| Professional | | $102.33 | $102.33 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.94 / $77.62 / $141.25
| Facility | | $7.94 | $77.62 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $144.54 / $173.78
| Professional | | $85.11 | $144.54 | $173.78 |