- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.05 / $142.37 / $142.37
| Professional | | $41.05 | $142.37 | $142.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.14 / $53.67 / $53.67
| Facility | | $40.14 | $53.67 | $53.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.14 / $53.67 / $53.67
| Professional | | $40.14 | $53.67 | $53.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.18 / $51.11 / $53.67
| Facility | | $25.18 | $51.11 | $53.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.14 / $40.28 / $53.71
| Professional | | $40.14 | $40.28 | $53.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.37 / $22.54 / $35.74
| Professional | | $20.37 | $22.54 | $35.74 |