- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $37.15 / $40.74
| Professional | | $33.88 | $37.15 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.74 / $40.74 / $40.74
| Facility | | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $40.74
| Professional | | $34.67 | $34.67 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.63 / $26.30 / $44.67
| Facility | | $2.63 | $26.30 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $33.88 / $50.12
| Professional | | $26.30 | $33.88 | $50.12 |