- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.68 / $23.68 / $23.68
| Facility | | $23.68 | $23.68 | $23.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.71 / $24.31 / $29.64
| Professional | | $15.71 | $24.31 | $29.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.23 / $25.13 / $35.04
| Professional | | $20.23 | $25.13 | $35.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.38 / $29.38 / $29.38
| Facility | | $29.38 | $29.38 | $29.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.85 / $60.51 / $72.62
| Professional | | $37.85 | $60.51 | $72.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.47 / $32.22 / $56.75
| Professional | | $25.47 | $32.22 | $56.75 |