- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $83.18 / $141.25
| Professional | | $67.61 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $251.19
| Facility | | $100.00 | $100.00 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $181.97
| Professional | | $72.44 | $72.44 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $81.28 / $190.55
| Facility | | $47.86 | $81.28 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $69.18 / $104.71
| Professional | | $46.77 | $69.18 | $104.71 |