- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.63 / $35.63 / $35.63
| Facility | | $35.63 | $35.63 | $35.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.47 / $25.71 / $25.71
| Professional | | $24.47 | $25.71 | $25.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.14 / $20.14 / $20.14
| Facility | | $20.14 | $20.14 | $20.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.20 / $35.52 / $57.92
| Professional | | $22.20 | $35.52 | $57.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.01 / $15.35 / $43.28
| Professional | | $13.01 | $15.35 | $43.28 |