- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.01 / $17.01 / $154.35
| Professional | | $17.01 | $17.01 | $154.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.65 / $36.65 / $36.65
| Facility | | $36.65 | $36.65 | $36.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.15 / $36.65 / $66.75
| Professional | | $31.15 | $36.65 | $66.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.28 / $36.70 / $53.01
| Professional | | $25.28 | $36.70 | $53.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.01 / $26.69 / $37.79
| Professional | | $17.01 | $26.69 | $37.79 |