- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.03 / $20.04 / $25.73
| Professional | | $19.03 | $20.04 | $25.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.27 / $35.52 / $57.86
| Professional | | $15.27 | $35.52 | $57.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.85 / $14.80 / $50.00
| Facility | | $13.85 | $14.80 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.36 / $17.00 / $49.77
| Professional | | $11.36 | $17.00 | $49.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.14 / $120.51 / $253.54
| Facility | | $44.14 | $120.51 | $253.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.55 / $2,796.55 / $2,796.55
| Professional | | $2,796.55 | $2,796.55 | $2,796.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.22 / $25.37 / $52.24
| Professional | | $15.22 | $25.37 | $52.24 |