- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.78 / $51.57 / $64.45
| Professional | | $40.78 | $51.57 | $64.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.33 / $34.45 / $100.00
| Facility | | $30.33 | $34.45 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.78 / $32.22 / $53.00
| Professional | | $8.78 | $32.22 | $53.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $53.00
| Facility | | $53.00 | $53.00 | $53.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.78 / $32.22 / $53.00
| Professional | | $8.78 | $32.22 | $53.00 |