- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.35 / $195.88 / $362.70
| Facility | | $57.35 | $195.88 | $362.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.88 / $19.37 / $19.67
| Professional | | $18.88 | $19.37 | $19.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.65 / $43.73 / $48.83
| Professional | | $32.65 | $43.73 | $48.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.78 / $25.03 / $31.47
| Professional | | $24.78 | $25.03 | $31.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.19 / $32.54 / $122.00
| Facility | | $15.19 | $32.54 | $122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.75 / $26.04 / $37.20
| Professional | | $10.75 | $26.04 | $37.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.11 / $15.18 / $37.20
| Professional | | $9.11 | $15.18 | $37.20 |