- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.03 / $25.65 / $27.14
| Professional | | $19.03 | $25.65 | $27.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.74 / $32.64 / $53.03
| Professional | | $27.74 | $32.64 | $53.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.65 / $36.65 / $36.65
| Facility | | $36.65 | $36.65 | $36.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.15 / $36.65 / $36.65
| Professional | | $31.15 | $36.65 | $36.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $30.45 / $50.75
| Professional | | $20.30 | $30.45 | $50.75 |