- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.90 / $108.90 / $6,907.00
| Facility | | $108.90 | $108.90 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.11 / $15.98 / $16.14
| Professional | | $14.11 | $15.98 | $16.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.57 / $22.22 / $25.85
| Professional | | $14.57 | $22.22 | $25.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.63 / $16.63 / $16.63
| Professional | | $16.63 | $16.63 | $16.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.86 / $19.80 / $42.61
| Professional | | $13.86 | $19.80 | $42.61 |