- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.65 / $18.05 / $18.05
| Facility | | $11.65 | $18.05 | $18.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.65 / $16.70 / $24.04
| Professional | | $11.65 | $16.70 | $24.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.00 / $53.00 / $124.55
| Professional | | $53.00 | $53.00 | $124.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.58 / $26.58 / $26.58
| Professional | | $26.58 | $26.58 | $26.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.06 / $87.42 / $87.42
| Facility | | $31.06 | $87.42 | $87.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.84 / $119.84 / $139.88
| Professional | | $119.84 | $119.84 | $139.88 |