- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.40 / $31.40 / $206.02
| Facility | | $31.40 | $31.40 | $206.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.57 / $22.66 / $22.66
| Professional | | $21.57 | $22.66 | $22.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.75 / $17.75 / $17.75
| Facility | | $17.75 | $17.75 | $17.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $31.39 / $39.24
| Professional | | $12.25 | $31.39 | $39.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.52 / $11.53 / $24.02
| Professional | | $8.52 | $11.53 | $24.02 |