- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.62 / $34.85 / $51.14
| Facility | | $20.62 | $34.85 | $51.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.62 / $20.62 / $1,280.00
| Professional | | $20.62 | $20.62 | $1,280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.90 / $11.65 / $8,639.91
| Facility | | $9.90 | $11.65 | $8,639.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.65 / $11.65 / $11.65
| Professional | | $11.65 | $11.65 | $11.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.62 / $31.75 / $51.14
| Facility | | $20.62 | $31.75 | $51.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.62 / $20.62 / $1,280.00
| Professional | | $20.62 | $20.62 | $1,280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.64 / $19.64 / $27.14
| Professional | | $19.64 | $19.64 | $27.14 |