- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.71 / $28.08 / $35.65
| Facility | | $24.71 | $28.08 | $35.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.32 / $24.71 / $35.65
| Professional | | $14.32 | $24.71 | $35.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.45 / $18.45 / $18.45
| Professional | | $18.45 | $18.45 | $18.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.50 / $50.00 / $80.00
| Professional | | $42.50 | $50.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.07 / $18.27 / $30.06
| Professional | | $3.07 | $18.27 | $30.06 |