- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.96 / $15.85 / $22.91
| Facility | | $10.96 | $15.85 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $15.85 / $33.88
| Professional | | $12.02 | $15.85 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $24.55 / $34.67
| Professional | | $16.98 | $24.55 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.59 / $15.49 / $15.49
| Professional | | $12.59 | $15.49 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $34.67 / $51.29
| Professional | | $25.70 | $34.67 | $51.29 |