- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.04 / $23.04 / $23.04
| Facility | | $23.04 | $23.04 | $23.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.82 / $25.57 / $148.15
| Professional | | $13.82 | $25.57 | $148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.04 / $23.04 / $23.04
| Professional | | $23.04 | $23.04 | $23.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.61 / $27.76 / $33.22
| Professional | | $20.61 | $27.76 | $33.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.04 / $23.04 / $23.04
| Facility | | $23.04 | $23.04 | $23.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.26 / $28.05 / $47.16
| Professional | | $12.26 | $28.05 | $47.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.53 / $23.04 / $43.11
| Professional | | $11.53 | $23.04 | $43.11 |