- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $12.02 / $54.95
| Professional | | $12.02 | $12.02 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.60 / $33.88 / $58.88
| Facility | | $16.60 | $33.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.47 / $3.47 / $3.47
| Professional | | $3.47 | $3.47 | $3.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $45.71 / $102.33
| Facility | | $22.39 | $45.71 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $199.53 / $346.74
| Professional | | $120.23 | $199.53 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |