- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $61.18 / $146.44
| Facility | | $18.55 | $61.18 | $146.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $18.55 / $20.63
| Professional | | $16.60 | $18.55 | $20.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.63 / $24.77 / $27.00
| Professional | | $22.63 | $24.77 | $27.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.22 / $21.16 / $50.36
| Professional | | $18.22 | $21.16 | $50.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.05 / $48.64 / $48.64
| Professional | | $22.05 | $48.64 | $48.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.82 / $22.05 / $60.96
| Professional | | $16.82 | $22.05 | $60.96 |