- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $112.20 / $239.88
| Professional | | $15.14 | $112.20 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.22 / $100.00 / $100.00
| Professional | | $11.22 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.14 / $134.90 / $239.88
| Facility | | $15.14 | $134.90 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |