- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.03 / $50.62 / $117.73
| Facility | | $24.03 | $50.62 | $117.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.03 / $24.03 / $24.03
| Professional | | $24.03 | $24.03 | $24.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.53 / $28.83 / $33.15
| Facility | | $25.53 | $28.83 | $33.15 |
- 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 / $20.72 / $20.72
| Professional | | $20.72 | $20.72 | $20.72 |