- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $13.07 / $16.92
| Facility | | $10.58 | $13.07 | $16.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $20.00
| Professional | | $10.58 | $10.58 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $200.00 / $345.10
| Professional | | $150.00 | $200.00 | $345.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.70 / $279.79 / $451.85
| Facility | | $54.70 | $279.79 | $451.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $206.48 / $255.54
| Professional | | $204.44 | $206.48 | $255.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $540.03
| Facility | | $10.58 | $10.58 | $540.03 |