- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.44 / $70.86 / $375.73
| Facility | | $30.44 | $70.86 | $375.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $37.54
| Professional | | $25.37 | $25.37 | $37.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $28.02
| Professional | | $25.37 | $25.37 | $28.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $32.31
| Professional | | $25.37 | $25.37 | $32.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $100.86
| Professional | | $25.37 | $25.37 | $100.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $26.89
| Professional | | $25.37 | $25.37 | $26.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.43 / $33.43 / $33.43
| Professional | | $33.43 | $33.43 | $33.43 |