- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $102.33 / $128.82
| Facility | | $34.67 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $72.44 / $158.49
| Professional | | $34.67 | $72.44 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $26.92 / $32.36
| Professional | | $25.70 | $26.92 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $1,862.09 / $1,862.09
| Professional | | $72.44 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $81.28
| Professional | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $18.62 / $23.44
| Professional | | $18.62 | $18.62 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $74.13 / $74.13
| Professional | | $64.57 | $74.13 | $74.13 |