- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.56 / $38.56 / $44.49
| Professional | | $38.56 | $38.56 | $44.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.03 / $37.03 / $58.07
| Facility | | $37.03 | $37.03 | $58.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.03 / $37.03 / $39.47
| Professional | | $27.03 | $37.03 | $39.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.03 / $37.03 / $58.07
| Facility | | $37.03 | $37.03 | $58.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.03 / $37.03 / $39.47
| Professional | | $27.03 | $37.03 | $39.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.28 / $46.80 / $91.34
| Professional | | $26.28 | $46.80 | $91.34 |