- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.87 / $23.88 / $75.17
| Professional | | $23.87 | $23.88 | $75.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.03 / $27.03 / $27.03
| Facility | | $27.03 | $27.03 | $27.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.53 / $31.35 / $52.25
| Facility | | $22.53 | $31.35 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $23.88 / $52.25
| Professional | | $23.88 | $23.88 | $52.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.53 / $31.35 / $52.25
| Facility | | $22.53 | $31.35 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $23.88 / $52.25
| Professional | | $23.88 | $23.88 | $52.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $25.31 / $68.41
| Professional | | $23.88 | $25.31 | $68.41 |