- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.45 / $28.45 / $32.83
| Professional | | $28.45 | $28.45 | $32.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.35 / $33.35 / $33.35
| Facility | | $33.35 | $33.35 | $33.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.22 / $24.35 / $24.35
| Professional | | $19.22 | $24.35 | $24.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.35 / $33.35 / $33.35
| Facility | | $33.35 | $33.35 | $33.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.22 / $24.35 / $24.35
| Professional | | $19.22 | $24.35 | $24.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.16 / $34.53 / $67.39
| Professional | | $20.16 | $34.53 | $67.39 |