- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $144.54
| Professional | | $39.81 | $57.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $186.21 / $218.78
| Facility | | $138.04 | $186.21 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $61.66 / $100.00
| Professional | | $45.71 | $61.66 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $72.44
| Facility | | $53.70 | $53.70 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $72.44
| Professional | | $52.48 | $52.48 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.77 / $57.54 / $128.82
| Facility | | $46.77 | $57.54 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $53.70 / $77.62
| Professional | | $42.66 | $53.70 | $77.62 |