- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.75 / $23.75 / $41.35
| Facility | | $23.75 | $23.75 | $41.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.64 / $23.75 / $30.51
| Professional | | $22.64 | $23.75 | $30.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.34 / $198.05 / $216.77
| Professional | | $168.34 | $198.05 | $216.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.08 / $35.11 / $51.84
| Professional | | $28.08 | $35.11 | $51.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.13 / $32.61 / $43.94
| Facility | | $23.13 | $32.61 | $43.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.68 / $18.50 / $67.84
| Professional | | $13.68 | $18.50 | $67.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.14 / $17.30 / $57.66
| Professional | | $13.14 | $17.30 | $57.66 |