- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.79 / $32.79 / $37.85
| Professional | | $32.79 | $32.79 | $37.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.54 / $34.54 / $49.40
| Facility | | $34.54 | $34.54 | $49.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.21 / $34.54 / $36.82
| Professional | | $25.21 | $34.54 | $36.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.54 / $34.54 / $49.40
| Facility | | $34.54 | $34.54 | $49.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.21 / $34.54 / $36.82
| Professional | | $25.21 | $34.54 | $36.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.58 / $50.51 / $55.89
| Professional | | $27.58 | $50.51 | $55.89 |