- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.68 / $50.73 / $206.68
| Facility | | $11.68 | $50.73 | $206.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.68 / $31.71 / $56.72
| Professional | | $11.68 | $31.71 | $56.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.77 / $13.77 / $13.77
| Professional | | $13.77 | $13.77 | $13.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.14 / $53.32 / $155.84
| Professional | | $13.14 | $53.32 | $155.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.06 / $119.46 / $119.46
| Professional | | $52.06 | $119.46 | $119.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.97 / $112.96 / $145.75
| Professional | | $39.97 | $112.96 | $145.75 |