- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.12 / $993.00 / $2,010.00
| Facility | | $13.12 | $993.00 | $2,010.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.88 / $13.12 / $16.66
| Professional | | $10.88 | $13.12 | $16.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.48 / $50.48 / $50.48
| Professional | | $50.48 | $50.48 | $50.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.25 / $38.25 / $45.00
| Professional | | $38.25 | $38.25 | $45.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.20 / $5.97 / $9.27
| Professional | | $5.20 | $5.97 | $9.27 |