- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.12 / $58.12 / $90.87
| Professional | | $58.12 | $58.12 | $90.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.35 / $101.35 / $101.35
| Facility | | $101.35 | $101.35 | $101.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.35 / $101.35 / $101.35
| Professional | | $101.35 | $101.35 | $101.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.65 / $69.65 / $112.40
| Facility | | $69.65 | $69.65 | $112.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.84 / $50.84 / $69.65
| Professional | | $50.84 | $50.84 | $69.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.36 / $45.77 / $50.81
| Professional | | $41.36 | $45.77 | $50.81 |