- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.57 / $114.57 / $156.12
| Facility | | $114.57 | $114.57 | $156.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.54 / $40.10 / $80.56
| Professional | | $32.54 | $40.10 | $80.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.69 / $37.43 / $42.78
| Professional | | $33.69 | $37.43 | $42.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.73 / $33.15 / $131.18
| Professional | | $25.73 | $33.15 | $131.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.47 / $64.16 / $80.20
| Professional | | $53.47 | $64.16 | $80.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.77 / $24.06 / $42.75
| Professional | | $16.77 | $24.06 | $42.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.74 / $42.51 / $42.51
| Professional | | $26.74 | $42.51 | $42.51 |