- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9.77 / $192.43 / $214.41
| Facility | | $9.77 | $192.43 | $214.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.11 / $9.66 / $11.38
| Professional | | $6.11 | $9.66 | $11.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $56.40 / $58.32
| Professional | | $24.00 | $56.40 | $58.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.72 / $10.72 / $10.72
| Professional | | $10.72 | $10.72 | $10.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Facility | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.13 / $75.13 / $106.73
| Professional | | $75.13 | $75.13 | $106.73 |