- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.50 / $294.41 / $755.15
| Facility | | $36.50 | $294.41 | $755.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $30.17 / $36.65
| Professional | | $28.73 | $30.17 | $36.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.36 / $27.36 / $30.17
| Professional | | $27.36 | $27.36 | $30.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.17 / $30.17 / $38.42
| Professional | | $30.17 | $30.17 | $38.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.17 / $30.17 / $42.19
| Professional | | $30.17 | $30.17 | $42.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.17 / $30.17 / $43.52
| Professional | | $30.17 | $30.17 | $43.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.76 / $30.76 / $30.76
| Professional | | $30.76 | $30.76 | $30.76 |