- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $33.59
| Facility | | $13.06 | $13.06 | $33.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $17.54
| Professional | | $13.06 | $13.06 | $17.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.02 / $37.60 / $42.20
| Professional | | $31.02 | $37.60 | $42.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.69 / $27.27
| Professional | | $21.48 | $21.69 | $27.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.06 / $22.20 / $88.64
| Facility | | $13.06 | $22.20 | $88.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.84 / $18.66 / $31.72
| Professional | | $7.84 | $18.66 | $31.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.84 / $18.66 / $27.06
| Professional | | $7.84 | $18.66 | $27.06 |