- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.36 / $40.84 / $107.77
| Facility | | $39.36 | $40.84 | $107.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.36 / $40.84 / $41.83
| Professional | | $39.36 | $40.84 | $41.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.86 / $25.72 / $25.72
| Facility | | $21.86 | $25.72 | $25.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.86 / $25.72 / $25.72
| Professional | | $21.86 | $25.72 | $25.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.00 / $22.88 / $22.88
| Facility | | $22.00 | $22.88 | $22.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.96 / $27.91 / $27.91
| Professional | | $13.96 | $27.91 | $27.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.58 / $71.44 / $71.44
| Professional | | $28.58 | $71.44 | $71.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.72 / $25.72 / $25.72
| Professional | | $25.72 | $25.72 | $25.72 |