- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.77 / $40.58 / $91.67
| Facility | | $31.77 | $40.58 | $91.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $51.27
| Professional | | $20.72 | $20.72 | $51.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.96 / $21.76 / $66.09
| Facility | | $18.96 | $21.76 | $66.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $22.06
| Professional | | $20.72 | $20.72 | $22.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Facility | | $20.72 | $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
- $20.72 / $22.47 / $23.71
| Professional | | $20.72 | $22.47 | $23.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |