- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $23.87 / $31.54
| Professional | | $21.27 | $23.87 | $31.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.38 / $165.38 / $165.38
| Facility | | $165.38 | $165.38 | $165.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.89 / $36.89 / $36.89
| Professional | | $36.89 | $36.89 | $36.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.27 / $28.33 / $45.10
| Facility | | $21.27 | $28.33 | $45.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.33 / $28.33 / $28.81
| Professional | | $28.33 | $28.33 | $28.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $1,500.00 / $3,000.00
| Professional | | $55.00 | $1,500.00 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.84 / $67.00 / $100.00
| Professional | | $43.84 | $67.00 | $100.00 |