- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.37 / $25.35 / $32.53
| Facility | | $22.37 | $25.35 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.53 / $32.53 / $32.53
| Professional | | $32.53 | $32.53 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.73 / $32.61 / $38.94
| Professional | | $27.73 | $32.61 | $38.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.11 / $32.53 / $40.67
| Professional | | $27.11 | $32.53 | $40.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.39 / $32.53 / $40.67
| Professional | | $11.39 | $32.53 | $40.67 |