- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.13 / $33.02 / $52.82
| Facility | | $22.13 | $33.02 | $52.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $22.23 / $28.20
| Professional | | $21.48 | $22.23 | $28.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.48 / $34.97 / $68.52
| Facility | | $21.48 | $34.97 | $68.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $22.62
| Professional | | $21.48 | $21.48 | $22.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.27 / $21.48 / $21.48
| Facility | | $20.27 | $21.48 | $21.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $21.48
| Professional | | $21.48 | $21.48 | $21.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $27.92
| Professional | | $21.48 | $21.48 | $27.92 |