- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.31 / $41.37 / $199.90
| Facility | | $22.31 | $41.37 | $199.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.33 / $16.10 / $16.10
| Professional | | $15.33 | $16.10 | $16.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.61 / $12.61 / $12.61
| Facility | | $12.61 | $12.61 | $12.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.85 / $22.30 / $36.32
| Professional | | $13.85 | $22.30 | $36.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.15 / $11.64 / $29.10
| Professional | | $8.15 | $11.64 | $29.10 |