- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $22.51 / $58.85
| Professional | | $22.51 | $22.51 | $58.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.64 / $52.64 / $52.64
| Facility | | $52.64 | $52.64 | $52.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $22.51 / $52.64
| Professional | | $22.51 | $22.51 | $52.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.64 / $52.64 / $52.64
| Facility | | $52.64 | $52.64 | $52.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $22.51 / $52.64
| Professional | | $22.51 | $22.51 | $52.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.07 / $23.39 / $50.99
| Professional | | $22.07 | $23.39 | $50.99 |