- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.10 / $30.07 / $133.00
| Professional | | $19.10 | $30.07 | $133.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.47 / $340.53 / $356.00
| Facility | | $155.47 | $340.53 | $356.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.54 / $33.54 / $33.54
| Facility | | $33.54 | $33.54 | $33.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.89 / $34.72 / $50.27
| Professional | | $13.89 | $34.72 | $50.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.54 / $33.54 / $33.54
| Facility | | $33.54 | $33.54 | $33.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.89 / $34.72 / $50.27
| Professional | | $13.89 | $34.72 | $50.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.76 / $29.07 / $46.32
| Professional | | $8.76 | $29.07 | $46.32 |