- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.51 / $26.51 / $36.20
| Professional | | $26.51 | $26.51 | $36.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $32.79 / $54.64
| Facility | | $20.83 | $32.79 | $54.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.51 / $26.51 / $54.64
| Professional | | $26.51 | $26.51 | $54.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $32.79 / $54.64
| Facility | | $20.83 | $32.79 | $54.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.51 / $26.51 / $54.64
| Professional | | $26.51 | $26.51 | $54.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.51 / $28.10 / $73.12
| Professional | | $26.51 | $28.10 | $73.12 |