- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.25 / $27.37 / $30.04
| Facility | | $21.25 | $27.37 | $30.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $28.52 / $32.20
| Professional | | $21.25 | $28.52 | $32.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.21 / $33.21 / $33.21
| Professional | | $33.21 | $33.21 | $33.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.75 / $25.45 / $45.00
| Professional | | $23.75 | $25.45 | $45.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $70.00 / $70.00
| Professional | | $50.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $37.00 / $37.00
| Professional | | $37.00 | $37.00 | $37.00 |