- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $38.90 / $58.88
| Professional | | $26.92 | $38.90 | $58.88 |
- 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 / $40.74 / $41.69
| Professional | | $34.67 | $40.74 | $41.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.55 / $26.92 / $39.81
| Facility | | $3.55 | $26.92 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $33.88 / $56.23
| Professional | | $20.42 | $33.88 | $56.23 |