- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.37 / $28.37 / $41.21
| Facility | | $28.37 | $28.37 | $41.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.37 / $41.21 / $41.21
| Professional | | $28.37 | $41.21 | $41.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.16 / $28.37 / $47.20
| Facility | | $13.16 | $28.37 | $47.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.37 / $31.70 / $41.21
| Professional | | $28.37 | $31.70 | $41.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.70 / $19.57 / $32.64
| Professional | | $17.70 | $19.57 | $32.64 |