- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.67 / $21.67 / $21.67
| Facility | | $21.67 | $21.67 | $21.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.02 / $21.67 / $32.35
| Professional | | $13.02 | $21.67 | $32.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.51 / $26.66 / $26.66
| Facility | | $22.51 | $26.66 | $26.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.66 / $22.66 / $31.36
| Professional | | $22.66 | $22.66 | $31.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.53 / $40.81 / $58.11
| Professional | | $40.53 | $40.81 | $58.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $15.00 / $29.51
| Professional | | $15.00 | $15.00 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.73 / $22.13 / $44.36
| Professional | | $17.73 | $22.13 | $44.36 |