- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.53 / $32.53 / $32.53
| Facility | | $32.53 | $32.53 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.53 / $32.53 / $32.53
| Professional | | $32.53 | $32.53 | $32.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.31 / $33.31 / $33.31
| Professional | | $33.31 | $33.31 | $33.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.35 / $37.54 / $60.00
| Professional | | $34.35 | $37.54 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.22 / $45.87 / $48.29
| Professional | | $37.22 | $45.87 | $48.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.65 / $32.65 / $32.65
| Professional | | $32.65 | $32.65 | $32.65 |