- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.41 / $38.79 / $86.85
| Facility | | $17.41 | $38.79 | $86.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $32.94
| Professional | | $20.00 | $20.00 | $32.94 |
- 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
- $22.10 / $22.10 / $22.10
| Professional | | $22.10 | $22.10 | $22.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.04 / $90.00 / $100.00
| Facility | | $27.04 | $90.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.35 / $22.35 / $26.37
| Professional | | $22.35 | $22.35 | $26.37 |