- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.00 / $86.40 / $86.40
| Facility | | $49.00 | $86.40 | $86.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $86.40
| Professional | | $30.00 | $50.00 | $86.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.05 / $17.76 / $45.66
| Facility | | $4.05 | $17.76 | $45.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.12 / $22.32 / $118.58
| Professional | | $1.12 | $22.32 | $118.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.38 / $128.38 / $128.38
| Professional | | $128.38 | $128.38 | $128.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $59.00 / $71.00
| Professional | | $45.00 | $59.00 | $71.00 |