- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.21 / $38.21 / $38.21
| Professional | | $38.21 | $38.21 | $38.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.00 / $88.00 / $110.00
| Professional | | $73.00 | $88.00 | $110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.97 / $62.78 / $90.80
| Professional | | $52.97 | $62.78 | $90.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.50 / $97.10 / $150.47
| Professional | | $60.50 | $97.10 | $150.47 |