- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.53 / $103.53 / $103.53
| Facility | | $103.53 | $103.53 | $103.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.03 / $9.14 / $14.80
| Professional | | $8.03 | $9.14 | $14.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.77 / $10.80 / $16.32
| Professional | | $8.77 | $10.80 | $16.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.46 / $8.30 / $15.77
| Facility | | $6.46 | $8.30 | $15.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.46 / $12.74 / $19.59
| Professional | | $6.46 | $12.74 | $19.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.18 / $15.23 / $18.27
| Professional | | $12.18 | $15.23 | $18.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $6.75 / $11.08
| Professional | | $5.48 | $6.75 | $11.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.75 / $6.09 / $11.77
| Professional | | $4.75 | $6.09 | $11.77 |