- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.57 / $19.18 / $37.29
| Facility | | $17.57 | $19.18 | $37.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.17 / $50.00 / $59.55
| Facility | | $2.17 | $50.00 | $59.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.21 / $40.27 / $115.39
| Professional | | $32.21 | $40.27 | $115.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.13 / $154.13 / $154.13
| Facility | | $154.13 | $154.13 | $154.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.32 / $14.28 / $34.28
| Professional | | $9.32 | $14.28 | $34.28 |