- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.27 / $33.92 / $102.87
| Facility | | $25.27 | $33.92 | $102.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $25.27
| Professional | | $25.27 | $25.27 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $46.84 / $79.20
| Professional | | $25.27 | $46.84 | $79.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.84 / $23.84 / $25.27
| Facility | | $23.84 | $23.84 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $21.48 / $25.27
| Professional | | $21.48 | $21.48 | $25.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.00 / $25.27 / $40.96
| Professional | | $23.00 | $25.27 | $40.96 |