- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.65 / $17.30 / $32.63
| Facility | | $15.65 | $17.30 | $32.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.36 / $14.40 / $17.30
| Professional | | $13.36 | $14.40 | $17.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.08 / $36.81 / $41.49
| Professional | | $32.08 | $36.81 | $41.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.55 / $14.44 / $15.57
| Professional | | $11.55 | $14.44 | $15.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.36 / $17.30 / $80.00
| Facility | | $11.36 | $17.30 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.19 / $111.19 / $111.19
| Professional | | $111.19 | $111.19 | $111.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $22.87 / $28.42
| Professional | | $18.44 | $22.87 | $28.42 |