- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $44.48 / $97.55
| Facility | | $20.72 | $44.48 | $97.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $26.69
| Professional | | $20.72 | $20.72 | $26.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.71 / $23.71 / $23.71
| Professional | | $23.71 | $23.71 | $23.71 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $100.00 / $100.00
| Facility | | $75.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $27.53
| Professional | | $20.72 | $20.72 | $27.53 |