- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.86 / $23.86 / $23.86
| Facility | | $23.86 | $23.86 | $23.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.86 / $23.86 / $23.86
| Professional | | $23.86 | $23.86 | $23.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.46 / $35.46 / $39.84
| Professional | | $35.46 | $35.46 | $39.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.11 / $32.11 / $32.11
| Professional | | $32.11 | $32.11 | $32.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.89 / $37.89 / $115.70
| Professional | | $37.89 | $37.89 | $115.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.38 / $29.08 / $61.16
| Professional | | $19.38 | $29.08 | $61.16 |