- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $269.15
| Professional | | $75.86 | $107.15 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $407.38
| Facility | | $251.19 | $346.74 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $91.20 / $186.21
| Professional | | $67.61 | $91.20 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $144.54
| Facility | | $100.00 | $100.00 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $144.54
| Professional | | $104.71 | $104.71 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $107.15 / $234.42
| Facility | | $85.11 | $107.15 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $100.00 / $144.54
| Professional | | $79.43 | $100.00 | $144.54 |