- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.72 / $29.72 / $141.15
| Facility | | $29.72 | $29.72 | $141.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $29.72 / $37.67
| Professional | | $22.51 | $29.72 | $37.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.10 / $26.10 / $27.09
| Professional | | $26.10 | $26.10 | $27.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.69 / $28.69 / $28.69
| Professional | | $28.69 | $28.69 | $28.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.58 / $71.67 / $103.68
| Professional | | $38.58 | $71.67 | $103.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.78 / $25.73 / $44.70
| Professional | | $19.78 | $25.73 | $44.70 |