- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.31 / $420.70 / $556.50
| Facility | | $115.31 | $420.70 | $556.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $212.83 / $477.23
| Professional | | $22.39 | $212.83 | $477.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.05 / $1.05 / $1.05
| Professional | | $1.05 | $1.05 | $1.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.62 / $45.98 / $80.47
| Facility | | $12.62 | $45.98 | $80.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.12 / $14.00 / $14.00
| Professional | | $6.12 | $14.00 | $14.00 |