- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.94 / $17.63 / $22.03
| Professional | | $13.94 | $17.63 | $22.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.75 / $26.60 / $90.00
| Facility | | $11.75 | $26.60 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $21.32 / $26.60
| Professional | | $11.75 | $21.32 | $26.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.75 / $11.75 / $24.00
| Facility | | $11.75 | $11.75 | $24.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $21.32 / $27.47
| Professional | | $11.75 | $21.32 | $27.47 |