- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.44 / $302.85 / $732.35
| Facility | | $86.44 | $302.85 | $732.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.72 / $35.72 / $35.72
| Professional | | $35.72 | $35.72 | $35.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.10 / $208.27 / $478.61
| Professional | | $38.10 | $208.27 | $478.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.40 / $80.50 / $172.60
| Facility | | $77.40 | $80.50 | $172.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.20 / $54.52 / $68.15
| Professional | | $26.20 | $54.52 | $68.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.82 / $96.82 / $96.82
| Professional | | $96.82 | $96.82 | $96.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $29.21 / $43.34
| Professional | | $20.00 | $29.21 | $43.34 |