- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.92 / $60.09 / $162.28
| Professional | | $57.92 | $60.09 | $162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.13 / $326.00 / $326.00
| Facility | | $105.13 | $326.00 | $326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.54 / $61.54 / $326.00
| Professional | | $61.54 | $61.54 | $326.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.40 / $64.50 / $326.00
| Facility | | $45.40 | $64.50 | $326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.54 / $75.43 / $139.82
| Professional | | $61.54 | $75.43 | $139.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.34 / $60.34 / $60.34
| Professional | | $60.34 | $60.34 | $60.34 |