- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.22 / $73.53 / $109.07
| Facility | | $10.22 | $73.53 | $109.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.22 / $12.71 / $13.22
| Professional | | $10.22 | $12.71 | $13.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.98 / $29.42 / $32.85
| Professional | | $21.98 | $29.42 | $32.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $17.10 / $21.50
| Professional | | $16.93 | $17.10 | $21.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.22 / $21.90 / $100.00
| Facility | | $10.22 | $21.90 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.24 / $17.52 / $25.04
| Professional | | $7.24 | $17.52 | $25.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.13 / $10.22 / $25.04
| Professional | | $6.13 | $10.22 | $25.04 |