- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.72 / $48.96 / $61.20
| Professional | | $38.72 | $48.96 | $61.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.29 / $33.19 / $100.00
| Facility | | $29.29 | $33.19 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.22 / $31.16 / $50.00
| Professional | | $13.22 | $31.16 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Facility | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.22 / $44.00 / $56.70
| Professional | | $13.22 | $44.00 | $56.70 |