- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.61 / $25.61 / $25.61
| Facility | | $25.61 | $25.61 | $25.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.61 / $25.61 / $25.61
| Professional | | $25.61 | $25.61 | $25.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.00 / $34.00 / $34.00
| Professional | | $34.00 | $34.00 | $34.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.30 / $23.30 / $23.30
| Professional | | $23.30 | $23.30 | $23.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.67 / $40.67 / $124.20
| Professional | | $40.67 | $40.67 | $124.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.81 / $29.09 / $58.43
| Professional | | $20.81 | $29.09 | $58.43 |