- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.28 / $36.53 / $36.53
| Professional | | $27.28 | $36.53 | $36.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $40.36
| Facility | | $40.36 | $40.36 | $40.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.31 / $40.36 / $41.57
| Professional | | $34.31 | $40.36 | $41.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $40.36
| Facility | | $40.36 | $40.36 | $40.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $41.57
| Professional | | $40.36 | $40.36 | $41.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.46 / $42.16 / $56.57
| Professional | | $20.46 | $42.16 | $56.57 |