- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.30 / $43.30 / $45.47
| Facility | | $43.30 | $43.30 | $45.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.75 / $42.28 / $43.30
| Professional | | $40.75 | $42.28 | $43.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.87 / $28.87 / $31.14
| Facility | | $15.87 | $28.87 | $31.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.87 / $28.87 / $28.87
| Professional | | $28.87 | $28.87 | $28.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.21 / $40.53 / $46.61
| Professional | | $39.21 | $40.53 | $46.61 |