- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.10 / $59.40 / $301.30
| Facility | | $26.10 | $59.40 | $301.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $39.40 / $76.83
| Facility | | $30.20 | $39.40 | $76.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.75 / $27.00 / $31.50
| Facility | | $24.75 | $27.00 | $31.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |