- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.61 / $105.33 / $159.22
| Facility | | $79.61 | $105.33 | $159.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.33 / $105.33 / $105.33
| Professional | | $105.33 | $105.33 | $105.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.88 / $16.84 / $22.66
| Facility | | $13.88 | $16.84 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.16 / $51.65 / $59.71
| Professional | | $49.16 | $51.65 | $59.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.75 / $67.28 / $3,138.00
| Facility | | $51.75 | $67.28 | $3,138.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $91.48 / $114.35
| Professional | | $91.48 | $91.48 | $114.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $44.26 / $111.21
| Professional | | $38.90 | $44.26 | $111.21 |