- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.48 / $25.48 / $863.03
| Facility | | $25.48 | $25.48 | $863.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.23 / $36.00 / $310.39
| Professional | | $0.23 | $36.00 | $310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.87 / $2.87 / $2.87
| Professional | | $2.87 | $2.87 | $2.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.23 / $100.00 / $760.00
| Facility | | $0.23 | $100.00 | $760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.68 / $45.68 / $45.68
| Professional | | $45.68 | $45.68 | $45.68 |