- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.67 / $270.00 / $270.00
| Facility | | $40.67 | $270.00 | $270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.32 / $21.96 / $22.23
| Professional | | $20.32 | $21.96 | $22.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.82 / $36.60 / $40.67
| Facility | | $29.82 | $36.60 | $40.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.53 / $32.53 / $36.60
| Professional | | $32.53 | $32.53 | $36.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.03 / $32.53 / $81.31
| Facility | | $22.03 | $32.53 | $81.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.39 / $39.24 / $130.66
| Professional | | $31.39 | $39.24 | $130.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $13.56 / $36.60
| Professional | | $11.39 | $13.56 | $36.60 |