- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.63 / $51.50 / $103.00
| Facility | | $38.63 | $51.50 | $103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $27.09 / $60.77
| Professional | | $18.57 | $27.09 | $60.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $33.90 / $60.00
| Professional | | $19.00 | $33.90 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.84 / $32.34 / $48.42
| Professional | | $24.84 | $32.34 | $48.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.93 / $28.65 / $38.20
| Professional | | $20.93 | $28.65 | $38.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.40 / $39.35 / $46.29
| Professional | | $23.40 | $39.35 | $46.29 |