- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $12.88 / $35.48
| Professional | | $10.00 | $12.88 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $33.88 / $41.69
| Professional | | $21.88 | $33.88 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $23.44 / $30.90
| Professional | | $16.60 | $23.44 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $295.12 / $3,090.30
| Facility | | $173.78 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $28.84 / $53.70
| Professional | | $18.62 | $28.84 | $53.70 |