- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.58 / $29.30 / $29.56
| Professional | | $21.58 | $29.30 | $29.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.83 / $94.29 / $111.63
| Facility | | $69.83 | $94.29 | $111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.65 / $27.82 / $44.66
| Professional | | $23.65 | $27.82 | $44.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.58 / $31.92 / $31.92
| Facility | | $28.58 | $31.92 | $31.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.30 / $31.92 / $31.92
| Professional | | $23.30 | $31.92 | $31.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.81 / $26.41 / $41.06
| Professional | | $20.81 | $26.41 | $41.06 |