- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.74 / $250.71 / $659.42
| Facility | | $51.74 | $250.71 | $659.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.02 / $87.35 / $106.08
| Professional | | $74.02 | $87.35 | $106.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.29 / $127.29 / $127.29
| Professional | | $127.29 | $127.29 | $127.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.12 / $87.12 / $87.12
| Professional | | $87.12 | $87.12 | $87.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.82 / $16.82 / $16.82
| Professional | | $16.82 | $16.82 | $16.82 |