- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $208.93
| Facility | | $15.85 | $15.85 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.38 / $45.71 / $93.33
| Professional | | $17.38 | $45.71 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $38.02 / $123.03
| Professional | | $19.05 | $38.02 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $45.71 / $91.20
| Professional | | $20.42 | $45.71 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $19.05 / $51.29
| Professional | | $16.98 | $19.05 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $31.62 / $60.26
| Professional | | $21.88 | $31.62 | $60.26 |