- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.35 / $87.41 / $195.04
| Facility | | $19.35 | $87.41 | $195.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.29 / $16.05 / $16.05
| Professional | | $15.29 | $16.05 | $16.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.58 / $12.58 / $12.58
| Facility | | $12.58 | $12.58 | $12.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.85 / $22.30 / $36.32
| Professional | | $13.85 | $22.30 | $36.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.59 / $51.47 / $129.41
| Facility | | $12.59 | $51.47 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.13 / $11.61 / $27.75
| Professional | | $8.13 | $11.61 | $27.75 |