- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.04 / $110.58 / $1,457.73
| Facility | | $4.04 | $110.58 | $1,457.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.52 / $9.07 / $9.07
| Professional | | $3.52 | $9.07 | $9.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.52 / $3.52 / $3.52
| Professional | | $3.52 | $3.52 | $3.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.09 / $64.38 / $84.54
| Facility | | $12.09 | $64.38 | $84.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.52 / $5.28 / $11.85
| Professional | | $3.52 | $5.28 | $11.85 |