- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.57 / $27.57 / $107.52
| Facility | | $27.57 | $27.57 | $107.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.53 / $22.68 / $35.18
| Professional | | $17.53 | $22.68 | $35.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.37 / $33.40 / $60.41
| Professional | | $18.37 | $33.40 | $60.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.26 / $723.20 / $1,992.59
| Facility | | $514.26 | $723.20 | $1,992.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.03 / $41.83 / $59.81
| Professional | | $22.03 | $41.83 | $59.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.17 / $33.84 / $48.80
| Professional | | $22.17 | $33.84 | $48.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.46 / $29.03 / $53.83
| Professional | | $18.46 | $29.03 | $53.83 |