- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.39 / $35.75 / $49.47
| Professional | | $35.39 | $35.75 | $49.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.80 / $20.80 / $20.80
| Professional | | $20.80 | $20.80 | $20.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.46 / $32.08 / $44.82
| Facility | | $25.46 | $32.08 | $44.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.80 / $37.95 / $10,000.00
| Professional | | $20.80 | $37.95 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.54 / $21.62 / $31.02
| Professional | | $19.54 | $21.62 | $31.02 |