- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $81.28 / $102.33
| Professional | | $44.67 | $81.28 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $89.13 / $1,000.00
| Professional | | $72.44 | $89.13 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $46.77 / $123.03
| Professional | | $46.77 | $46.77 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $104.71 / $104.71
| Professional | | $83.18 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $64.57 / $141.25
| Professional | | $50.12 | $64.57 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $47.86 / $69.18
| Professional | | $33.88 | $47.86 | $69.18 |