- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.40 / $32.40 / $32.40
| Facility | | $32.40 | $32.40 | $32.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.39 / $32.78 / $47.90
| Professional | | $29.39 | $32.78 | $47.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.00 / $52.00 / $52.00
| Professional | | $52.00 | $52.00 | $52.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.40 / $36.94 / $68.95
| Facility | | $32.40 | $36.94 | $68.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.40 / $70.47 / $262.88
| Professional | | $39.40 | $70.47 | $262.88 |