- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.25 / $55.00 / $82.75
| Facility | | $21.25 | $55.00 | $82.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $38.00 / $75.61
| Professional | | $21.25 | $38.00 | $75.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.70 / $42.00 / $80.00
| Professional | | $35.70 | $42.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.11 / $200.00 / $425.00
| Professional | | $20.11 | $200.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $51.70 / $78.00
| Professional | | $38.00 | $51.70 | $78.00 |