- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $87.10 / $104.71
| Professional | | $83.18 | $87.10 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $109.65
| Professional | | $79.43 | $79.43 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $30.20
| Professional | | $0.60 | $0.60 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Facility | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $104.71 / $117.49
| Professional | | $93.33 | $104.71 | $117.49 |