- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.74 / $17.35 / $30.67
| Professional | | $11.74 | $17.35 | $30.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.00 / $30.16 / $56.13
| Professional | | $26.00 | $30.16 | $56.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,052.30 / $16,052.30 / $16,052.30
| Facility | | $16,052.30 | $16,052.30 | $16,052.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $60.00
| Professional | | $50.00 | $50.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $28.00 / $53.00
| Professional | | $25.00 | $28.00 | $53.00 |