- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.10 / $58.70 / $73.41
| Professional | | $58.10 | $58.70 | $73.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.18 / $30.18 / $30.18
| Professional | | $30.18 | $30.18 | $30.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.72 / $45.00 / $62.88
| Facility | | $35.72 | $45.00 | $62.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.18 / $62.31 / $10,000.00
| Professional | | $30.18 | $62.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.35 / $31.37 / $45.00
| Professional | | $28.35 | $31.37 | $45.00 |