- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.26 / $46.60 / $83.17
| Facility | | $28.26 | $46.60 | $83.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.03 / $34.78 / $58.81
| Professional | | $20.03 | $34.78 | $58.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.10 / $22.10 / $22.10
| Facility | | $22.10 | $22.10 | $22.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.43 / $45.43 / $45.43
| Professional | | $45.43 | $45.43 | $45.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.13 / $25.26 / $29.09
| Professional | | $22.13 | $25.26 | $29.09 |