- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $151.36
| Facility | | $100.00 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $162.18
| Professional | | $100.00 | $151.36 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $13.49 / $17.38
| Professional | | $3.02 | $13.49 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $10.47 / $23.44
| Professional | | $8.13 | $10.47 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.99 / $23.99 / $30.20
| Professional | | $23.99 | $23.99 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |