- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $13.63 / $8,500.00
| Facility | | $13.63 | $13.63 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.63 / $13.63 / $67.02
| Professional | | $13.63 | $13.63 | $67.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.25 / $32.25 / $40.31
| Professional | | $32.25 | $32.25 | $40.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $13.63 / $101.84
| Facility | | $13.63 | $13.63 | $101.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.30 / $38.85 / $50.93
| Professional | | $21.30 | $38.85 | $50.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.76 / $41.38 / $61.98
| Professional | | $22.76 | $41.38 | $61.98 |