- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.36 / $25.86 / $30.14
| Facility | | $22.36 | $25.86 | $30.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.84 / $22.36 / $26.31
| Professional | | $21.84 | $22.36 | $26.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Facility | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $26.31
| Professional | | $21.05 | $21.05 | $26.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.36 / $23.70 / $28.94
| Facility | | $22.36 | $23.70 | $28.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.69 / $18.69 / $18.69
| Professional | | $18.69 | $18.69 | $18.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $27.37
| Professional | | $21.05 | $21.05 | $27.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.84 / $100.00 / $113.76
| Facility | | $39.84 | $100.00 | $113.76 |