- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.87 / $43.32 / $43.32
| Professional | | $31.87 | $43.32 | $43.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.36 / $40.36 / $41.60
| Facility | | $40.36 | $40.36 | $41.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.31 / $40.36 / $71.63
| Professional | | $34.31 | $40.36 | $71.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.64 / $43.32 / $56.57
| Facility | | $21.64 | $43.32 | $56.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.00 / $48.00 / $48.00
| Professional | | $48.00 | $48.00 | $48.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.64 / $31.91 / $53.61
| Professional | | $21.64 | $31.91 | $53.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.84 / $292.83 / $292.83
| Facility | | $92.84 | $292.83 | $292.83 |