- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.02 / $21.02 / $54.05
| Facility | | $21.02 | $21.02 | $54.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.02 / $23.98 / $45.04
| Professional | | $21.02 | $23.98 | $45.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.21 / $60.51 / $67.56
| Professional | | $45.21 | $60.51 | $67.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.69 / $34.69 / $50.93
| Professional | | $34.69 | $34.69 | $50.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.82 / $21.62 / $54.05
| Facility | | $16.82 | $21.62 | $54.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.03 / $34.39 / $164.83
| Professional | | $14.03 | $34.39 | $164.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.61 / $30.63 / $51.05
| Professional | | $12.61 | $30.63 | $51.05 |