- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.56 / $28.56 / $196.26
| Professional | | $28.56 | $28.56 | $196.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.54 / $41.54 / $55.62
| Facility | | $41.54 | $41.54 | $55.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.31 / $41.54 / $72.75
| Professional | | $35.31 | $41.54 | $72.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.69 / $46.18 / $60.03
| Professional | | $28.69 | $46.18 | $60.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.83 / $32.83 / $44.91
| Professional | | $32.83 | $32.83 | $44.91 |