- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.62 / $21.62 / $41.35
| Facility | | $21.62 | $21.62 | $41.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.62 / $27.02 / $27.02
| Professional | | $21.62 | $27.02 | $27.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.75 / $9.85 / $12.38
| Professional | | $9.75 | $9.85 | $12.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.54 / $21.62 / $64.86
| Facility | | $19.54 | $21.62 | $64.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.52 / $22.52 / $24.46
| Professional | | $22.52 | $22.52 | $24.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.14 / $22.52 / $24.46
| Professional | | $19.14 | $22.52 | $24.46 |