- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.36 / $34.60 / $43.25
| Professional | | $27.36 | $34.60 | $43.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.92 / $23.21 / $100.00
| Facility | | $20.92 | $23.21 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $22.16 / $35.00
| Professional | | $19.00 | $22.16 | $35.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.00 / $35.00 / $35.00
| Facility | | $35.00 | $35.00 | $35.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.93 / $31.00 / $39.67
| Professional | | $20.93 | $31.00 | $39.67 |