- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $245.47
| Facility | | $10.47 | $10.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $102.33 / $1,000.00
| Professional | | $0.02 | $102.33 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.09 / $64.57 / $64.57
| Facility | | $3.09 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Professional | | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $54.95 / $199.53
| Professional | | $34.67 | $54.95 | $199.53 |