- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.43 / $137.69 / $496.00
| Professional | | $50.43 | $137.69 | $496.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.13 / $50.00 / $50.00
| Facility | | $45.13 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.42 / $100.42 / $1,632.00
| Professional | | $100.42 | $100.42 | $1,632.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.57 / $228.57 / $228.57
| Facility | | $228.57 | $228.57 | $228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.89 / $99.89 / $228.57
| Professional | | $99.89 | $99.89 | $228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.28 / $63.28 / $63.28
| Professional | | $63.28 | $63.28 | $63.28 |