- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.76 / $30.76 / $32.94
| Facility | | $30.76 | $30.76 | $32.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.87 / $26.96 / $32.94
| Professional | | $21.87 | $26.96 | $32.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.04 / $58.73 / $63.38
| Facility | | $57.04 | $58.73 | $63.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.85 / $28.06 / $39.96
| Professional | | $23.85 | $28.06 | $39.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.85 / $32.33 / $58.66
| Professional | | $23.85 | $32.33 | $58.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.75 / $35.51 / $48.78
| Professional | | $25.75 | $35.51 | $48.78 |