- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.41 / $31.55 / $65.66
| Professional | | $17.41 | $31.55 | $65.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.82 / $29.46 / $70.81
| Professional | | $18.82 | $29.46 | $70.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $48.20 / $75.81
| Professional | | $27.54 | $48.20 | $75.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.67 / $48.58 / $84.80
| Professional | | $26.67 | $48.58 | $84.80 |