- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.84 / $28.39 / $43.24
| Facility | | $21.84 | $28.39 | $43.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.84 / $21.84
| Professional | | $21.05 | $21.84 | $21.84 |
- 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 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.84 / $113.76 / $113.76
| Facility | | $39.84 | $113.76 | $113.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $22.36
| Professional | | $21.05 | $21.05 | $22.36 |