- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.70 / $26.41 / $160.57
| Facility | | $23.70 | $26.41 | $160.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.41 / $26.41 / $27.09
| Professional | | $26.41 | $26.41 | $27.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.86 / $35.54 / $46.73
| Professional | | $33.86 | $35.54 | $46.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.56 / $68.67 / $193.07
| Facility | | $22.56 | $68.67 | $193.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.41 / $33.86 / $40.97
| Facility | | $26.41 | $33.86 | $40.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.22 / $19.30 / $33.86
| Professional | | $14.22 | $19.30 | $33.86 |