- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.94 / $64.94 / $196.53
| Facility | | $64.94 | $64.94 | $196.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $63.11 / $63.11
| Professional | | $25.27 | $63.11 | $63.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $25.27 / $25.27
| Professional | | $25.27 | $25.27 | $25.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.28 / $47.28 / $47.28
| Facility | | $47.28 | $47.28 | $47.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.27 / $33.36 / $40.88
| Professional | | $25.27 | $33.36 | $40.88 |