- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.07 / $43.08 / $53.86
| Professional | | $34.07 | $43.08 | $53.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.15 / $28.98 / $100.00
| Facility | | $26.15 | $28.98 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $27.26 / $44.00
| Professional | | $24.00 | $27.26 | $44.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.00 / $44.00 / $44.00
| Facility | | $44.00 | $44.00 | $44.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.13 / $38.00 / $49.52
| Professional | | $26.13 | $38.00 | $49.52 |