- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.91 / $48.91 / $56.43
| Professional | | $48.91 | $48.91 | $56.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.32 / $57.32 / $57.32
| Facility | | $57.32 | $57.32 | $57.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.63 / $41.84 / $41.84
| Professional | | $33.63 | $41.84 | $41.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.32 / $57.32 / $57.32
| Facility | | $57.32 | $57.32 | $57.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.63 / $41.84 / $41.84
| Professional | | $33.63 | $41.84 | $41.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $59.36 / $115.87
| Professional | | $34.67 | $59.36 | $115.87 |