- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.86 / $61.96 / $68.73
| Facility | | $33.86 | $61.96 | $68.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.75 / $61.96 / $68.73
| Professional | | $26.75 | $61.96 | $68.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.86 / $33.86 / $33.86
| Facility | | $33.86 | $33.86 | $33.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.86 / $33.86 / $33.86
| Professional | | $33.86 | $33.86 | $33.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.22 / $20.32 / $57.56
| Professional | | $14.22 | $20.32 | $57.56 |