- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.45 / $181.45 / $181.45
| Facility | | $181.45 | $181.45 | $181.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.18 / $5.18 / $16.53
| Professional | | $5.18 | $5.18 | $16.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.31 / $2.72 / $3.17
| Facility | | $1.31 | $2.72 | $3.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.46 / $12.46 / $25.30
| Professional | | $12.46 | $12.46 | $25.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.80 / $23.32 / $45.52
| Professional | | $17.80 | $23.32 | $45.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $15.12 / $18.76
| Professional | | $10.58 | $15.12 | $18.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.69 / $20.03 / $29.44
| Professional | | $16.69 | $20.03 | $29.44 |