- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.77 / $17.77 / $156.60
| Facility | | $17.77 | $17.77 | $156.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.21 / $12.82 / $12.82
| Professional | | $12.21 | $12.82 | $12.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.03 / $10.03 / $10.03
| Facility | | $10.03 | $10.03 | $10.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.30 / $17.76 / $26.50
| Professional | | $10.30 | $17.76 | $26.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.45 / $15.45 / $64.33
| Facility | | $15.45 | $15.45 | $64.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.65 / $7.07 / $23.18
| Professional | | $3.65 | $7.07 | $23.18 |