- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.30 / $19.50 / $22.49
| Professional | | $19.30 | $19.50 | $22.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.24 / $11.24 / $11.24
| Professional | | $11.24 | $11.24 | $11.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.62 / $18.78 / $23.97
| Facility | | $13.62 | $18.78 | $23.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.24 / $20.70 / $10,000.00
| Professional | | $11.24 | $20.70 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.56 / $11.69 / $16.76
| Professional | | $10.56 | $11.69 | $16.76 |