- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.20 / $187.20 / $426.60
| Facility | | $187.20 | $187.20 | $426.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.86 / $18.26 / $22.83
| Professional | | $9.86 | $18.26 | $22.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.73 / $21.07 / $28.21
| Facility | | $17.73 | $21.07 | $28.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.73 / $18.73 / $18.73
| Professional | | $18.73 | $18.73 | $18.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.72 / $2.22 / $46.68
| Facility | | $0.72 | $2.22 | $46.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.77 / $17.00 / $87.29
| Professional | | $7.77 | $17.00 | $87.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.75 / $9.14 / $22.68
| Professional | | $7.75 | $9.14 | $22.68 |