- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.40 / $11.40 / $21.71
| Facility | | $11.40 | $11.40 | $21.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.80 / $14.47 / $21.71
| Professional | | $7.80 | $14.47 | $21.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.04 / $204.46 / $204.46
| Facility | | $57.04 | $204.46 | $204.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.59 / $14.58 / $17.67
| Professional | | $7.59 | $14.58 | $17.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.77 / $15.77 / $15.77
| Professional | | $15.77 | $15.77 | $15.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.21 / $20.44 / $30.59
| Professional | | $17.21 | $20.44 | $30.59 |