- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.96 / $63.48 / $211.38
| Facility | | $17.96 | $63.48 | $211.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.64 / $14.33 / $17.96
| Professional | | $13.64 | $14.33 | $17.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.82 / $19.82 / $24.78
| Professional | | $19.82 | $19.82 | $24.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.94 / $45.94 / $115.50
| Facility | | $45.94 | $45.94 | $115.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.04 / $8.28 / $17.27
| Professional | | $6.04 | $8.28 | $17.27 |