- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.66 / $138.51 / $290.70
| Facility | | $131.66 | $138.51 | $290.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.86 / $22.02 / $29.76
| Professional | | $9.86 | $22.02 | $29.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.36 / $17.36 / $17.36
| Facility | | $17.36 | $17.36 | $17.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.54 / $13.96 / $32.70
| Professional | | $7.54 | $13.96 | $32.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.74 / $91.74 / $91.74
| Facility | | $91.74 | $91.74 | $91.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.70 / $11.27 / $27.27
| Professional | | $7.70 | $11.27 | $27.27 |