- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.52 / $34.52 / $34.52
| Facility | | $34.52 | $34.52 | $34.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $31.76 / $34.52
| Professional | | $22.12 | $31.76 | $34.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.27 / $36.27 / $43.65
| Professional | | $27.27 | $36.27 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.68 / $34.52 / $46.60
| Facility | | $22.68 | $34.52 | $46.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.41 / $14.41 / $14.41
| Professional | | $14.41 | $14.41 | $14.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.55 / $25.94 / $34.36
| Professional | | $12.55 | $25.94 | $34.36 |