- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.02 / $20.02 / $20.02
| Facility | | $20.02 | $20.02 | $20.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.28 / $20.28 / $24.70
| Professional | | $16.28 | $20.28 | $24.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.27 / $26.78 / $28.36
| Professional | | $21.27 | $26.78 | $28.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $22.61
| Facility | | $20.72 | $20.72 | $22.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.61 / $20.72 / $27.20
| Professional | | $17.61 | $20.72 | $27.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.28 / $148.63 / $148.63
| Facility | | $42.28 | $148.63 | $148.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.49 / $16.60 / $23.75
| Professional | | $10.49 | $16.60 | $23.75 |