- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.83 / $41.83 / $70.16
| Professional | | $41.83 | $41.83 | $70.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.86 / $21.86 / $25.72
| Facility | | $21.86 | $21.86 | $25.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.72 / $25.72 / $25.72
| Professional | | $25.72 | $25.72 | $25.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.86 / $21.86 / $25.72
| Facility | | $21.86 | $21.86 | $25.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.72 / $25.72 / $25.72
| Professional | | $25.72 | $25.72 | $25.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.72 / $71.44 / $75.73
| Professional | | $60.72 | $71.44 | $75.73 |