- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.37 / $74.78 / $74.78
| Professional | | $13.37 | $74.78 | $74.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.86 / $22.68 / $34.36
| Facility | | $16.86 | $22.68 | $34.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.00 / $16.52 / $16.86
| Professional | | $8.00 | $16.52 | $16.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.86 / $19.77 / $34.36
| Facility | | $16.86 | $19.77 | $34.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $11.63 / $16.86
| Professional | | $10.47 | $11.63 | $16.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.88 / $6.65 / $19.91
| Professional | | $4.88 | $6.65 | $19.91 |