- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.50 / $35.48 / $100.00
| Facility | | $19.50 | $35.48 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $14.13 / $51.29
| Professional | | $12.88 | $14.13 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.96 / $10.96 / $10.96
| Facility | | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $19.50 / $31.62
| Professional | | $12.02 | $19.50 | $31.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.98 / $41.69 / $81.28
| Facility | | $16.98 | $41.69 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $10.47 / $25.12
| Professional | | $7.08 | $10.47 | $25.12 |