- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.53 / $34.88 / $47.08
| Professional | | $25.53 | $34.88 | $47.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.22 / $35.22 / $35.22
| Facility | | $35.22 | $35.22 | $35.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.07 / $31.07 / $31.07
| Professional | | $31.07 | $31.07 | $31.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.45 / $45.24 / $47.56
| Professional | | $38.45 | $45.24 | $47.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.47 / $34.88 / $68.13
| Professional | | $24.47 | $34.88 | $68.13 |