- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $25.37
| Facility | | $25.37 | $25.37 | $25.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.22 / $26.89 / $163.13
| Professional | | $15.22 | $26.89 | $163.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.37 / $25.37 / $25.37
| Professional | | $25.37 | $25.37 | $25.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.86 / $31.71 / $35.27
| Professional | | $21.86 | $31.71 | $35.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.56 / $21.56 / $25.37
| Facility | | $21.56 | $21.56 | $25.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.05 / $29.38 / $51.88
| Professional | | $13.05 | $29.38 | $51.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.93 / $25.37 / $47.47
| Professional | | $11.93 | $25.37 | $47.47 |