- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.70 / $22.70 / $24.97
| Facility | | $22.70 | $22.70 | $24.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.17 / $43.17 / $51.54
| Professional | | $43.17 | $43.17 | $51.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.48 / $20.97 / $32.72
| Facility | | $17.48 | $20.97 | $32.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.16 / $20.39 / $139.32
| Professional | | $17.16 | $20.39 | $139.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.07 / $19.80 / $32.86
| Professional | | $17.07 | $19.80 | $32.86 |