- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $30.32 / $30.32
| Facility | | $30.32 | $30.32 | $30.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.32 / $38.00 / $55.04
| Professional | | $30.32 | $38.00 | $55.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.53 / $21.45 / $35.09
| Facility | | $11.53 | $21.45 | $35.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.32 / $33.75 / $55.04
| Facility | | $30.32 | $33.75 | $55.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.62 / $52.38 / $81.67
| Professional | | $43.62 | $52.38 | $81.67 |