- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.26 / $29.51 / $38.32
| Professional | | $29.26 | $29.51 | $38.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.68 / $38.68 / $38.68
| Facility | | $38.68 | $38.68 | $38.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.68 / $38.68 / $38.68
| Professional | | $38.68 | $38.68 | $38.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.44 / $32.44 / $39.28
| Professional | | $32.44 | $32.44 | $39.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.81 / $20.81 / $20.81
| Professional | | $20.81 | $20.81 | $20.81 |