- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.51 / $27.51 / $1,053.83
| Facility | | $27.51 | $27.51 | $1,053.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.01 / $28.19 / $37.09
| Professional | | $19.01 | $28.19 | $37.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.22 / $42.88 / $49.06
| Facility | | $33.22 | $42.88 | $49.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.00 / $31.46 / $31.46
| Professional | | $28.00 | $31.46 | $31.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.82 / $39.78 / $57.04
| Professional | | $16.82 | $39.78 | $57.04 |