- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.46 / $138.46 / $138.46
| Facility | | $138.46 | $138.46 | $138.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.41 / $17.54 / $24.08
| Professional | | $17.41 | $17.54 | $24.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.52 / $28.52 / $66.01
| Facility | | $25.52 | $28.52 | $66.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.64 / $18.05 / $18.05
| Professional | | $12.64 | $18.05 | $18.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.00 / $77.69 / $136.57
| Facility | | $71.00 | $77.69 | $136.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.43 / $25.13 / $31.41
| Professional | | $21.43 | $25.13 | $31.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.43 / $16.80 / $47.64
| Professional | | $8.43 | $16.80 | $47.64 |