- 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
- $18.82 / $19.14 / $43.32
| Professional | | $18.82 | $19.14 | $43.32 |
- 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
- $28.67 / $39.32 / $47.43
| Facility | | $28.67 | $39.32 | $47.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.54 / $43.35 / $61.80
| Professional | | $31.54 | $43.35 | $61.80 |