- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.00 / $70.76 / $230.00
| Professional | | $68.00 | $70.76 | $230.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.11 / $36.11 / $36.11
| Professional | | $36.11 | $36.11 | $36.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.08 / $63.11 / $88.18
| Facility | | $50.08 | $63.11 | $88.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.11 / $74.52 / $10,000.00
| Professional | | $36.11 | $74.52 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.93 / $37.54 / $53.86
| Professional | | $33.93 | $37.54 | $53.86 |