- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.88 / $17.88 / $111.55
| Facility | | $17.88 | $17.88 | $111.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.34 / $14.47 / $17.88
| Professional | | $10.34 | $14.47 | $17.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.55 / $37.89 / $43.81
| Facility | | $31.55 | $37.89 | $43.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $18.86 / $31.28
| Professional | | $13.20 | $18.86 | $31.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.39 / $84.63 / $117.60
| Professional | | $19.39 | $84.63 | $117.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.55 / $17.67 / $26.43
| Professional | | $13.55 | $17.67 | $26.43 |