- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.70 / $271.70 / $271.70
| Facility | | $271.70 | $271.70 | $271.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $17.85 / $35.40
| Professional | | $10.34 | $17.85 | $35.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.07 / $19.98 / $37.26
| Professional | | $11.07 | $19.98 | $37.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.10 / $39.04 / $92.55
| Professional | | $19.10 | $39.04 | $92.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.39 / $32.29 / $51.83
| Professional | | $17.39 | $32.29 | $51.83 |