- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.75 / $376.63 / $1,021.08
| Facility | | $22.75 | $376.63 | $1,021.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.75 / $159.31 / $487.17
| Professional | | $22.75 | $159.31 | $487.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.84 / $76.88 / $672.48
| Professional | | $25.84 | $76.88 | $672.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.19 / $129.38 / $545.86
| Professional | | $25.19 | $129.38 | $545.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.55 / $54.45 / $517.60
| Facility | | $22.55 | $54.45 | $517.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.65 / $220.55 / $570.04
| Professional | | $26.65 | $220.55 | $570.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.21 / $308.57 / $342.85
| Professional | | $34.21 | $308.57 | $342.85 |