- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.40 / $26.26 / $33.59
| Professional | | $23.40 | $26.26 | $33.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.01 / $37.01 / $37.01
| Facility | | $37.01 | $37.01 | $37.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.01 / $37.01 / $37.01
| Professional | | $37.01 | $37.01 | $37.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.79 / $27.79 / $42.16
| Facility | | $27.79 | $27.79 | $42.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.62 / $27.79 / $32.86
| Professional | | $23.62 | $27.79 | $32.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.46 / $21.40 / $39.83
| Professional | | $13.46 | $21.40 | $39.83 |