- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.62 / $20.62 / $1,116.00
| Facility | | $20.62 | $20.62 | $1,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $20.62 / $34.29
| Professional | | $19.89 | $20.62 | $34.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.43 / $135.22 / $181.92
| Facility | | $111.43 | $135.22 | $181.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.64 / $19.64 / $20.42
| Professional | | $19.64 | $19.64 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.64 / $19.64 / $19.64
| Professional | | $19.64 | $19.64 | $19.64 |