- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.59 / $75.14 / $146.51
| Facility | | $57.59 | $75.14 | $146.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.89 / $34.60 / $43.25
| Professional | | $21.89 | $34.60 | $43.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.71 / $12.71 / $12.71
| Professional | | $12.71 | $12.71 | $12.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.83 / $38.83 / $38.83
| Facility | | $38.83 | $38.83 | $38.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.83 / $38.83 / $38.83
| Professional | | $38.83 | $38.83 | $38.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.71 / $12.71 / $12.71
| Professional | | $12.71 | $12.71 | $12.71 |