- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.44 / $204.17 / $204.17
| Facility | | $23.44 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $18.62 / $26.92
| Professional | | $7.08 | $18.62 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.14 / $34.67 / $34.67
| Professional | | $15.14 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $21.38 / $21.38
| Professional | | $21.38 | $21.38 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $22.91 / $52.48
| Professional | | $10.00 | $22.91 | $52.48 |