- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.71 / $30.27 / $80.73
| Facility | | $20.71 | $30.27 | $80.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $21.75 / $27.97
| Professional | | $20.72 | $21.75 | $27.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.56 / $20.72 / $20.72
| Facility | | $5.56 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.89 / $20.72 / $26.94
| Professional | | $19.89 | $20.72 | $26.94 |