- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $97.72 / $263.03
| Professional | | $72.44 | $97.72 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.17 / $85.11 / $144.54
| Facility | | $0.17 | $85.11 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $125.89 / $177.83
| Professional | | $107.15 | $125.89 | $177.83 |