- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.02 / $198.02 / $198.02
| Facility | | $198.02 | $198.02 | $198.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $13.51 / $20.78
| Professional | | $7.76 | $13.51 | $20.78 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $3.71 / $5.41 / $10.39
| Professional | 52 | $3.71 | $5.41 | $10.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.74 / $18.73 / $19.85
| Professional | | $14.74 | $18.73 | $19.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.10 / $17.23 / $24.03
| Professional | | $9.10 | $17.23 | $24.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.77 / $15.77 / $15.77
| Professional | | $15.77 | $15.77 | $15.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.36 / $16.57 / $27.79
| Facility | | $10.36 | $16.57 | $27.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.12 / $21.54 / $116.07
| Professional | | $15.12 | $21.54 | $116.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.10 / $19.32 / $33.01
| Professional | | $15.10 | $19.32 | $33.01 |