- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.24 / $241.71 / $241.71
| Professional | | $15.24 | $241.71 | $241.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.25 / $100.00 / $100.00
| Professional | | $11.25 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.03 / $14.03 / $449.45
| Professional | | $14.03 | $14.03 | $449.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.24 / $158.00 / $241.71
| Facility | | $15.24 | $158.00 | $241.71 |
- 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
- $108.39 / $108.39 / $108.39
| Professional | | $108.39 | $108.39 | $108.39 |