- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.65 / $10.65 / $27.38
| Facility | | $10.65 | $10.65 | $27.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.65 / $13.69 / $14.30
| Professional | | $10.65 | $13.69 | $14.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.90 / $30.65 / $34.22
| Professional | | $22.90 | $30.65 | $34.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.35 / $17.52 / $22.03
| Professional | | $17.35 | $17.52 | $22.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.65 / $22.82 / $86.70
| Facility | | $10.65 | $22.82 | $86.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.54 / $18.25 / $26.08
| Professional | | $7.54 | $18.25 | $26.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.39 / $10.64 / $26.08
| Professional | | $6.39 | $10.64 | $26.08 |