- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.24 / $158.06 / $200.77
| Facility | | $30.24 | $158.06 | $200.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $10.30 / $10.30
| Professional | | $10.30 | $10.30 | $10.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.61 / $37.50 / $84.67
| Professional | | $9.61 | $37.50 | $84.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.30 / $23.19 / $50.00
| Facility | | $22.30 | $23.19 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.46 / $15.69 / $19.62
| Professional | | $7.46 | $15.69 | $19.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.91 / $27.91 / $27.91
| Professional | | $27.91 | $27.91 | $27.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.19 / $12.49 / $12.81
| Professional | | $5.19 | $12.49 | $12.81 |