- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.87 / $114.21 / $151.61
| Professional | | $84.87 | $114.21 | $151.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.16 / $141.16 / $141.16
| Facility | | $141.16 | $141.16 | $141.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.10 / $148.22 / $190.57
| Professional | | $134.10 | $148.22 | $190.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.55 / $67.76 / $204.38
| Professional | | $48.55 | $67.76 | $204.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.12 / $114.21 / $151.61
| Professional | | $85.12 | $114.21 | $151.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.14 / $66.29 / $89.60
| Professional | | $55.14 | $66.29 | $89.60 |