- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.24 / $10.24 / $22.69
| Facility | | $10.24 | $10.24 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.37 / $16.67 / $22.69
| Professional | | $7.37 | $16.67 | $22.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.93 / $34.10 / $62.25
| Professional | | $28.93 | $34.10 | $62.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $62.25
| Professional | | $20.83 | $20.83 | $62.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $62.25
| Professional | | $20.83 | $20.83 | $62.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.95 / $32.31 / $93.93
| Professional | | $21.95 | $32.31 | $93.93 |