- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.96 / $38.63 / $41.40
| Professional | | $23.96 | $38.63 | $41.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.16 / $24.16 / $26.58
| Facility | | $24.16 | $24.16 | $26.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.23 / $20.23 / $24.16
| Professional | | $20.23 | $20.23 | $24.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.96 / $38.63 / $52.70
| Facility | | $23.96 | $38.63 | $52.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.50 / $41.40 / $244.02
| Professional | | $34.50 | $41.40 | $244.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.50 / $39.10 / $67.68
| Professional | | $34.50 | $39.10 | $67.68 |