- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.11 / $52.11 / $248.14
| Facility | | $52.11 | $52.11 | $248.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.04 / $32.57 / $32.57
| Professional | | $20.04 | $32.57 | $32.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.74 / $34.74 / $39.60
| Professional | | $34.74 | $34.74 | $39.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.02 / $23.02 / $23.02
| Professional | | $23.02 | $23.02 | $23.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.43 / $52.12 / $65.15
| Professional | | $43.43 | $52.12 | $65.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.23 / $19.54 / $39.09
| Professional | | $18.23 | $19.54 | $39.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.72 / $21.72 / $21.72
| Professional | | $21.72 | $21.72 | $21.72 |