- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $25.70 / $28.18
| Professional | | $22.91 | $25.70 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Facility | | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $23.44 / $27.54
| Professional | | $23.44 | $23.44 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.82 / $18.20 / $34.67
| Facility | | $1.82 | $18.20 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $22.91 / $30.90
| Professional | | $16.98 | $22.91 | $30.90 |