- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.50 / $20.29 / $30.54
| Professional | | $18.50 | $20.29 | $30.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.02 / $19.95 / $36.72
| Professional | | $7.02 | $19.95 | $36.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $37.25 / $61.18
| Professional | | $24.51 | $37.25 | $61.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.68 / $35.32 / $36.04
| Professional | | $32.68 | $35.32 | $36.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.42 / $19.61 / $36.04
| Professional | | $14.42 | $19.61 | $36.04 |