- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $74.13 / $100.00
| Professional | | $37.15 | $74.13 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $91.20 / $141.25
| Facility | | $77.62 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $56.23 / $123.03
| Professional | | $30.20 | $56.23 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Facility | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $45.71 / $64.57
| Professional | | $30.20 | $45.71 | $64.57 |