- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $151.36
| Professional | | $102.33 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $20.89 / $89.13
| Professional | | $10.47 | $20.89 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $275.42 / $275.42
| Professional | | $263.03 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $16.98 / $16.98
| Professional | | $16.98 | $16.98 | $16.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.32 / $9.12 / $91.20
| Facility | | $8.32 | $9.12 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.24 / $97.72 / $134.90
| Professional | | $7.24 | $97.72 | $134.90 |