- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.09 / $34.53 / $53.57
| Professional | | $31.09 | $34.53 | $53.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.05 / $20.94 / $34.89
| Facility | | $18.05 | $20.94 | $34.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $20.41 / $20.41
| Professional | | $20.41 | $20.41 | $20.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.05 / $20.94 / $34.89
| Facility | | $18.05 | $20.94 | $34.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $20.41 / $20.41
| Professional | | $20.41 | $20.41 | $20.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.95 / $34.68 / $53.35
| Professional | | $32.95 | $34.68 | $53.35 |