- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.21 / $50.92 / $63.65
| Professional | | $32.21 | $50.92 | $63.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.61 / $100.00 / $100.00
| Facility | | $40.61 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $51.00 / $51.00
| Professional | | $51.00 | $51.00 | $51.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.13 / $25.13 / $35.18
| Facility | | $25.13 | $25.13 | $35.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.00 / $45.00 / $58.78
| Professional | | $14.00 | $45.00 | $58.78 |