- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.54 / $30.54 / $45.24
| Facility | | $30.54 | $30.54 | $45.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.51 / $30.54 / $30.54
| Professional | | $15.51 | $30.54 | $30.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.63 / $19.63 / $19.63
| Professional | | $19.63 | $19.63 | $19.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.38 / $22.38 / $22.38
| Facility | | $22.38 | $22.38 | $22.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.25 / $32.72 / $32.72
| Professional | | $22.25 | $32.72 | $32.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.80 / $24.23 / $49.69
| Facility | | $14.80 | $24.23 | $49.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.62 / $22.72 / $28.39
| Professional | | $11.62 | $22.72 | $28.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.57 / $22.57 / $22.57
| Professional | | $22.57 | $22.57 | $22.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19.63 / $19.63 / $19.63
| Facility | | $19.63 | $19.63 | $19.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.24 / $11.78 / $19.63
| Professional | | $8.24 | $11.78 | $19.63 |