- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.36 / $10.36 / $26.64
| Facility | | $10.36 | $10.36 | $26.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.36 / $13.32 / $13.42
| Professional | | $10.36 | $13.32 | $13.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.37 / $29.82 / $33.47
| Professional | | $22.37 | $29.82 | $33.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.93 / $17.10 / $21.50
| Professional | | $16.93 | $17.10 | $21.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.36 / $22.20 / $162.06
| Facility | | $10.36 | $22.20 | $162.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.22 / $17.76 / $25.38
| Professional | | $6.22 | $17.76 | $25.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.22 / $10.35 / $25.38
| Professional | | $6.22 | $10.35 | $25.38 |