- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.63 / $158.65 / $165.57
| Facility | | $134.63 | $158.65 | $165.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.55 / $12.76 / $28.88
| Professional | | $12.55 | $12.76 | $28.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $70.00 / $1,500.00
| Professional | | $60.00 | $70.00 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.14 / $24.05 / $26.45
| Facility | | $19.14 | $24.05 | $26.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $26.51 / $37.21
| Professional | | $19.00 | $26.51 | $37.21 |