- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.75 / $114.66 / $114.66
| Facility | | $33.75 | $114.66 | $114.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.75 / $17.32 / $19.23
| Professional | | $12.75 | $17.32 | $19.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.00 / $22.00 / $22.00
| Professional | | $18.00 | $22.00 | $22.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Facility | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.17 / $21.02 / $32.34
| Professional | | $16.17 | $21.02 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.45 / $14.80 / $16.57
| Professional | | $13.45 | $14.80 | $16.57 |