- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.40 / $52.40 / $134.75
| Facility | | $52.40 | $52.40 | $134.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.40 / $54.11 / $54.52
| Professional | | $52.40 | $54.11 | $54.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.45 / $150.84 / $169.28
| Professional | | $124.45 | $150.84 | $169.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.90 / $86.76 / $109.10
| Professional | | $85.90 | $86.76 | $109.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.40 / $100.57 / $355.59
| Facility | | $52.40 | $100.57 | $355.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.69 / $89.83 / $128.36
| Professional | | $35.69 | $89.83 | $128.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.44 / $76.36 / $128.36
| Professional | | $31.44 | $76.36 | $128.36 |