- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $102.00
| Professional | | $102.00 | $102.00 | $102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.60 / $25.46 / $50.51
| Facility | | $17.60 | $25.46 | $50.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.62 / $17.59 / $28.21
| Professional | | $5.62 | $17.59 | $28.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.59 / $23.23 / $27.73
| Professional | | $18.59 | $23.23 | $27.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.09 / $30.09 / $32.02
| Professional | | $30.09 | $30.09 | $32.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.13 / $16.14 / $48.84
| Professional | | $11.13 | $16.14 | $48.84 |