- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $104.71 / $104.71
| Facility | | $22.39 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $22.91 / $44.67
| Professional | | $12.88 | $22.91 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $40.74 / $44.67
| Professional | | $27.54 | $40.74 | $44.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $22.39 / $22.39
| Facility | | $22.39 | $22.39 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.62 / $29.51 / $72.44
| Professional | | $18.62 | $29.51 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $22.39 / $44.67
| Professional | | $13.49 | $22.39 | $44.67 |