- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.73 / $28.73 / $32.09
| Facility | | $28.73 | $28.73 | $32.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $32.09 / $40.07
| Professional | | $28.73 | $32.09 | $40.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.65 / $41.65 / $41.65
| Professional | | $41.65 | $41.65 | $41.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.64 / $41.64 / $53.03
| Professional | | $41.64 | $41.64 | $53.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.20 / $31.58 / $40.79
| Professional | | $27.20 | $31.58 | $40.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.14 / $47.14 / $68.00
| Professional | | $47.14 | $47.14 | $68.00 |