- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $100.00
| Professional | | $79.43 | $79.43 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.62 / $64.57 / $354.81
| Facility | | $31.62 | $64.57 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $245.47 / $245.47
| Professional | | $52.48 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $63.10 / $63.10
| Professional | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $63.10
| Professional | | $57.54 | $57.54 | $63.10 |