- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.63 / $661.13 / $772.94
| Facility | | $30.63 | $661.13 | $772.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.63 / $30.63 / $76.70
| Professional | | $30.63 | $30.63 | $76.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.27 / $37.85 / $260.20
| Professional | | $35.27 | $37.85 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.11 / $40.38 / $149.37
| Professional | | $29.11 | $40.38 | $149.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.88 / $77.16 / $77.16
| Professional | | $36.88 | $77.16 | $77.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.73 / $45.34 / $111.80
| Professional | | $29.73 | $45.34 | $111.80 |