- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.54 / $101.27 / $136.46
| Facility | | $35.54 | $101.27 | $136.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.54 / $35.54 / $35.54
| Professional | | $35.54 | $35.54 | $35.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.54 / $35.54 / $35.90
| Professional | | $35.54 | $35.54 | $35.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.54 / $33.54 / $35.54
| Facility | | $33.54 | $33.54 | $35.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.22 / $30.22 / $35.54
| Professional | | $30.22 | $30.22 | $35.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.35 / $35.54 / $57.62
| Professional | | $32.35 | $35.54 | $57.62 |