- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.43 / $19.47 / $25.02
| Professional | | $17.43 | $19.47 | $25.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.37 / $27.37 / $27.37
| Facility | | $27.37 | $27.37 | $27.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.37 / $27.37 / $27.37
| Professional | | $27.37 | $27.37 | $27.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.72 / $20.72 / $31.41
| Facility | | $20.72 | $20.72 | $31.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.61 / $20.72 / $27.20
| Professional | | $17.61 | $20.72 | $27.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.18 / $16.61 / $39.84
| Professional | | $10.18 | $16.61 | $39.84 |