- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.85 / $12.85 / $33.04
| Facility | | $12.85 | $12.85 | $33.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.85 / $12.85 / $17.26
| Professional | | $12.85 | $12.85 | $17.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.52 / $37.00 / $41.52
| Professional | | $30.52 | $37.00 | $41.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.06 / $21.27 / $26.75
| Professional | | $21.06 | $21.27 | $26.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.85 / $25.28 / $87.21
| Facility | | $12.85 | $25.28 | $87.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.71 / $22.03 / $31.21
| Professional | | $7.71 | $22.03 | $31.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.71 / $18.73 / $28.14
| Professional | | $7.71 | $18.73 | $28.14 |