- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.88 / $1,614.00 / $7,727.00
| Facility | | $11.88 | $1,614.00 | $7,727.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $28.00
| Professional | | $11.88 | $11.88 | $28.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.86 / $7.86 / $8.10
| Professional | | $7.86 | $7.86 | $8.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.27 / $22.18 / $22.18
| Professional | | $7.27 | $22.18 | $22.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.40 / $7.86 / $12.36
| Professional | | $5.40 | $7.86 | $12.36 |