- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.83 / $25.83 / $27.18
| Facility | | $25.83 | $25.83 | $27.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $22.40 / $27.77
| Professional | | $21.00 | $22.40 | $27.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.81 / $23.81 / $35.79
| Professional | | $23.81 | $23.81 | $35.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.43 / $41.83 / $65.01
| Professional | | $19.43 | $41.83 | $65.01 |