- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.63 / $25.52 / $43.38
| Facility | | $23.63 | $25.52 | $43.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.53 / $25.54 / $26.27
| Professional | | $25.53 | $25.54 | $26.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.08 / $20.63 / $32.72
| Facility | | $13.08 | $20.63 | $32.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.31 / $22.31 / $23.65
| Facility | | $22.31 | $22.31 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.63 / $25.52 / $75.00
| Facility | | $23.63 | $25.52 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.13 / $23.63 / $23.65
| Professional | | $23.13 | $23.63 | $23.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $23.65 / $23.65
| Professional | | $23.65 | $23.65 | $23.65 |