- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.00 / $23.33 / $63.62
| Facility | | $6.00 | $23.33 | $63.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $9.88 / $30.45
| Professional | | $6.00 | $9.88 | $30.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.94 / $26.94 / $26.94
| Professional | | $26.94 | $26.94 | $26.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.33 / $33.44 / $33.44
| Professional | | $24.33 | $33.44 | $33.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.85 / $22.20 / $40.63
| Professional | | $12.85 | $22.20 | $40.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $34.38
| Professional | | $23.65 | $23.65 | $34.38 |