- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.67 / $49.16 / $58.91
| Professional | | $48.67 | $49.16 | $58.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.61 / $28.61 / $28.61
| Professional | | $28.61 | $28.61 | $28.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.85 / $42.66 / $59.61
| Facility | | $33.85 | $42.66 | $59.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.61 / $52.19 / $10,000.00
| Professional | | $28.61 | $52.19 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.87 / $29.74 / $42.66
| Professional | | $26.87 | $29.74 | $42.66 |