- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.44 / $32.94 / $51.81
| Professional | | $32.44 | $32.94 | $51.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.83 / $66.25 / $85.35
| Professional | | $35.83 | $66.25 | $85.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.44 / $41.71 / $64.86
| Facility | | $32.44 | $41.71 | $64.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.77 / $168.77 / $168.77
| Facility | | $168.77 | $168.77 | $168.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.41 / $227.41 / $260.25
| Professional | | $227.41 | $227.41 | $260.25 |