- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $65.68
| Facility | | $21.05 | $21.05 | $65.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.94 / $39.85 / $75.38
| Facility | | $22.94 | $39.85 | $75.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $25.25
| Professional | | $21.05 | $21.05 | $25.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.64 / $36.84 / $65.68
| Facility | | $20.64 | $36.84 | $65.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.64 / $21.05 / $25.27
| Professional | | $20.64 | $21.05 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $22.33
| Professional | | $21.05 | $21.05 | $22.33 |