- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $46.77 / $72.44
| Professional | | $21.38 | $46.77 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $10,000.00
| Professional | | $125.89 | $125.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $346.74 / $346.74
| Professional | | $100.00 | $346.74 | $346.74 |
- 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
- $39.81 / $2,511.89 / $2,511.89
| Professional | | $39.81 | $2,511.89 | $2,511.89 |