- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.23 / $22.23 / $22.23
| Facility | | $22.23 | $22.23 | $22.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $24.68 / $142.94
| Professional | | $13.34 | $24.68 | $142.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.79 / $38.32 / $53.72
| Professional | | $27.79 | $38.32 | $53.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.23 / $22.23 / $22.23
| Facility | | $22.23 | $22.23 | $22.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.54 / $29.74 / $83.70
| Professional | | $18.54 | $29.74 | $83.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.34 / $22.67 / $45.41
| Professional | | $13.34 | $22.67 | $45.41 |