- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.51 / $25.51 / $65.75
| Facility | | $25.51 | $25.51 | $65.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.02 / $48.70 / $54.02
| Professional | | $21.02 | $48.70 | $54.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.31 / $13.31 / $13.31
| Professional | | $13.31 | $13.31 | $13.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.85 / $36.85 / $36.85
| Professional | | $36.85 | $36.85 | $36.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.08 / $28.17 / $62.39
| Professional | | $12.08 | $28.17 | $62.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.29 / $29.27 / $66.53
| Professional | | $16.29 | $29.27 | $66.53 |