- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.58 / $62.20 / $62.21
| Professional | | $61.58 | $62.20 | $62.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.15 / $31.15 / $31.15
| Professional | | $31.15 | $31.15 | $31.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.85 / $48.96 / $68.40
| Facility | | $38.85 | $48.96 | $68.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.15 / $66.04 / $10,000.00
| Professional | | $31.15 | $66.04 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.93 / $32.38 / $53.96
| Professional | | $29.93 | $32.38 | $53.96 |