- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.58 / $82.65 / $397.44
| Facility | | $14.58 | $82.65 | $397.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.30 / $21.30 / $49.42
| Professional | | $21.30 | $21.30 | $49.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.31 / $21.31 / $21.31
| Professional | | $21.31 | $21.31 | $21.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.25 / $17.89 / $138.25
| Facility | | $13.25 | $17.89 | $138.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.80 / $21.31 / $31.97
| Professional | | $19.80 | $21.31 | $31.97 |