- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.72 / $51.86 / $51.86
| Professional | | $38.72 | $51.86 | $51.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.52 / $54.52 / $54.52
| Facility | | $54.52 | $54.52 | $54.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.34 / $54.52 / $56.16
| Professional | | $46.34 | $54.52 | $56.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.52 / $54.52 / $54.52
| Facility | | $54.52 | $54.52 | $54.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.52 / $54.52 / $56.16
| Professional | | $54.52 | $54.52 | $56.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.97 / $61.18 / $80.30
| Professional | | $27.97 | $61.18 | $80.30 |