- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.63 / $56.63 / $70.78
| Professional | | $56.63 | $56.63 | $70.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.08 / $53.76 / $72.44
| Facility | | $40.08 | $53.76 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $163.00 / $163.00
| Professional | | $40.00 | $163.00 | $163.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Facility | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $48.00 / $53.92
| Professional | | $40.00 | $48.00 | $53.92 |