- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.35 / $112.70 / $112.70
| Facility | | $102.35 | $112.70 | $112.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.73 / $57.72 / $118.45
| Professional | | $41.73 | $57.72 | $118.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.02 / $22.38 / $113.11
| Professional | | $19.02 | $22.38 | $113.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.82 / $51.82 / $51.82
| Facility | | $51.82 | $51.82 | $51.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.22 / $38.22 / $43.09
| Professional | | $38.22 | $38.22 | $43.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.20 / $58.24 / $102.44
| Professional | | $44.20 | $58.24 | $102.44 |