- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.70 / $24.70 / $253.08
| Facility | | $24.70 | $24.70 | $253.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.97 / $17.82 / $17.82
| Professional | | $16.97 | $17.82 | $17.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.96 / $13.96 / $13.96
| Facility | | $13.96 | $13.96 | $13.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.45 / $24.37 / $40.25
| Professional | | $15.45 | $24.37 | $40.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.02 / $12.89 / $30.01
| Professional | | $9.02 | $12.89 | $30.01 |