- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.85 / $30.93 / $45.53
| Professional | | $27.85 | $30.93 | $45.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.17 / $23.01 / $38.34
| Facility | | $22.17 | $23.01 | $38.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.85 / $27.85 / $27.85
| Professional | | $27.85 | $27.85 | $27.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.17 / $23.01 / $38.34
| Facility | | $22.17 | $23.01 | $38.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.85 / $27.85 / $27.85
| Professional | | $27.85 | $27.85 | $27.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.46 / $29.52 / $73.12
| Professional | | $26.46 | $29.52 | $73.12 |