- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.42 / $100.44 / $100.44
| Facility | | $51.42 | $100.44 | $100.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.34 / $51.42 / $51.42
| Professional | | $24.34 | $51.42 | $51.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.22 / $33.22 / $56.71
| Facility | | $33.22 | $33.22 | $56.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.25 / $33.22 / $49.66
| Professional | | $24.25 | $33.22 | $49.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.85 / $25.27 / $39.00
| Professional | | $16.85 | $25.27 | $39.00 |