- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.38 / $28.38 / $63.86
| Facility | | $28.38 | $28.38 | $63.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.38 / $35.47 / $35.47
| Professional | | $28.38 | $35.47 | $35.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.13 / $31.13 / $38.90
| Professional | | $31.13 | $31.13 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.38 / $35.47 / $48.25
| Facility | | $28.38 | $35.47 | $48.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.08 / $30.08 / $32.67
| Professional | | $30.08 | $30.08 | $32.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.57 / $30.08 / $33.09
| Professional | | $25.57 | $30.08 | $33.09 |