- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.19 / $212.00 / $316.72
| Facility | | $130.19 | $212.00 | $316.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.66 / $34.13 / $81.53
| Professional | | $12.66 | $34.13 | $81.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.05 / $1.05 / $1.05
| Professional | | $1.05 | $1.05 | $1.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.62 / $45.98 / $80.47
| Facility | | $12.62 | $45.98 | $80.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $5.09
| Professional | | $5.00 | $5.00 | $5.09 |