- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.26 / $30.43 / $112.67
| Facility | | $25.26 | $30.43 | $112.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $46.56
| Professional | | $25.27 | $25.27 | $46.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $27.53
| Professional | | $25.27 | $25.27 | $27.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $25.27
| Facility | | $25.27 | $25.27 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $51.66
| Professional | | $25.27 | $25.27 | $51.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.08 / $25.27 / $25.27
| Professional | | $24.08 | $25.27 | $25.27 |