- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $12.86 / $33.07
| Facility | | $12.86 | $12.86 | $33.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $16.37 / $16.66
| Professional | | $12.86 | $16.37 | $16.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.76 / $37.02 / $41.54
| Professional | | $27.76 | $37.02 | $41.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.06 / $21.27 / $26.75
| Professional | | $21.06 | $21.27 | $26.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.86 / $27.56 / $334.35
| Facility | | $12.86 | $27.56 | $334.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.11 / $22.04 / $31.50
| Professional | | $9.11 | $22.04 | $31.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.72 / $22.04 / $31.50
| Professional | | $7.72 | $22.04 | $31.50 |