- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.04 / $103.25 / $103.25
| Facility | | $14.04 | $103.25 | $103.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.04 / $18.85 / $23.98
| Professional | | $14.04 | $18.85 | $23.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.19 / $40.40 / $45.11
| Professional | | $30.19 | $40.40 | $45.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.13 / $23.13 / $33.95
| Professional | | $23.13 | $23.13 | $33.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.03 / $18.85 / $146.52
| Facility | | $12.03 | $18.85 | $146.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.03 / $29.07 / $180.90
| Professional | | $12.03 | $29.07 | $180.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.42 / $25.66 / $34.09
| Professional | | $8.42 | $25.66 | $34.09 |