- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.62 / $103.04 / $200.72
| Facility | | $21.62 | $103.04 | $200.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.62 / $21.62 / $21.62
| Professional | | $21.62 | $21.62 | $21.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.06 / $126.11 / $288.39
| Professional | | $23.06 | $126.11 | $288.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.85 / $48.72 / $104.75
| Facility | | $46.85 | $48.72 | $104.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.87 / $33.04 / $41.30
| Professional | | $15.87 | $33.04 | $41.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.60 / $58.60 / $58.60
| Professional | | $58.60 | $58.60 | $58.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.97 / $17.68 / $26.23
| Professional | | $12.97 | $17.68 | $26.23 |