- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.77 / $10.77 / $27.70
| Facility | | $10.77 | $10.77 | $27.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.42 / $13.95 / $14.47
| Professional | | $13.42 | $13.95 | $14.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.17 / $31.01 / $34.63
| Professional | | $23.17 | $31.01 | $34.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.76 / $17.94 / $22.55
| Professional | | $17.76 | $17.94 | $22.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.77 / $23.09 / $111.86
| Facility | | $10.77 | $23.09 | $111.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.70 / $18.47 / $30.78
| Professional | | $7.70 | $18.47 | $30.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $10.77 / $26.39
| Professional | | $6.46 | $10.77 | $26.39 |