- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.67 / $55.05 / $83.38
| Facility | | $31.67 | $55.05 | $83.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.67 / $31.67 / $60.00
| Professional | | $31.67 | $31.67 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.09 / $24.09 / $24.29
| Facility | | $24.09 | $24.09 | $24.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.32 / $32.76 / $32.76
| Facility | | $26.32 | $32.76 | $32.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.76 / $32.76 / $32.76
| Professional | | $32.76 | $32.76 | $32.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.26 / $32.51 / $34.95
| Professional | | $29.26 | $32.51 | $34.95 |