- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.33 / $26.33 / $26.33
| Professional | | $26.33 | $26.33 | $26.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.56 / $24.56 / $24.56
| Facility | | $24.56 | $24.56 | $24.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.33 / $26.33 / $39.58
| Facility | | $26.33 | $26.33 | $39.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.76 / $27.52 / $31.01
| Professional | | $25.76 | $27.52 | $31.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $150.43 / $150.43
| Facility | | $75.00 | $150.43 | $150.43 |