- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.80 / $43.80 / $50.54
| Professional | | $43.80 | $43.80 | $50.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.03 / $57.03 / $57.03
| Facility | | $57.03 | $57.03 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.88 / $44.02 / $58.74
| Professional | | $39.88 | $44.02 | $58.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.03 / $57.03 / $57.03
| Facility | | $57.03 | $57.03 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.88 / $57.03 / $58.74
| Professional | | $39.88 | $57.03 | $58.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.85 / $53.17 / $103.76
| Professional | | $29.85 | $53.17 | $103.76 |