- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.23 / $119.45 / $2,012.44
| Facility | | $25.23 | $119.45 | $2,012.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.56 / $43.67 / $61.25
| Professional | | $25.56 | $43.67 | $61.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.32 / $44.75 / $80.51
| Professional | | $27.32 | $44.75 | $80.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.80 / $108.80 / $182.75
| Facility | | $108.80 | $108.80 | $182.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.56 / $81.69 / $103.18
| Professional | | $44.56 | $81.69 | $103.18 |