- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.22 / $21.22 / $1,785.01
| Facility | | $21.22 | $21.22 | $1,785.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.22 / $21.22 / $21.22
| Professional | | $21.22 | $21.22 | $21.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.06 / $25.65 / $27.34
| Facility | | $21.06 | $25.65 | $27.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.30 / $18.30 / $18.30
| Professional | | $18.30 | $18.30 | $18.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.52 / $36.02 / $51.71
| Facility | | $27.52 | $36.02 | $51.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.30 / $18.30 / $18.30
| Professional | | $18.30 | $18.30 | $18.30 |