- 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
- $51.32 / $51.32 / $51.32
| Facility | | $51.32 | $51.32 | $51.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.46 / $51.32 / $57.66
| Professional | | $37.46 | $51.32 | $57.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.32 / $51.32 / $51.32
| Facility | | $51.32 | $51.32 | $51.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.46 / $51.32 / $57.66
| Professional | | $37.46 | $51.32 | $57.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.21 / $67.45 / $74.63
| Professional | | $37.21 | $67.45 | $74.63 |