- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.21 / $65.31 / $183.97
| Facility | | $53.21 | $65.31 | $183.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.62 / $10.62 / $12.86
| Professional | | $10.62 | $10.62 | $12.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.30 / $13.30 / $13.30
| Professional | | $13.30 | $13.30 | $13.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.45 / $33.45 / $33.45
| Professional | | $33.45 | $33.45 | $33.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $10.62 / $13.24
| Professional | | $9.77 | $10.62 | $13.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.62 / $10.62 / $11.26
| Professional | | $10.62 | $10.62 | $11.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.62 / $10.62 / $10.62
| Professional | | $10.62 | $10.62 | $10.62 |