- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.47 / $29.64 / $34.81
| Professional | | $22.47 | $29.64 | $34.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.83 / $33.83 / $33.83
| Professional | | $33.83 | $33.83 | $33.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.57 / $28.13 / $42.00
| Facility | | $25.57 | $28.13 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.26 / $74.26 / $74.26
| Professional | | $74.26 | $74.26 | $74.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,000.00 / $3,900.00
| Professional | | $30.00 | $2,000.00 | $3,900.00 |