- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.55 / $47.55 / $74.36
| Professional | | $47.55 | $47.55 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.49 / $33.49 / $52.65
| Facility | | $33.49 | $33.49 | $52.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.07 / $47.55 / $52.65
| Professional | | $46.07 | $47.55 | $52.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.49 / $33.49 / $52.65
| Facility | | $33.49 | $33.49 | $52.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.10 / $47.55 / $52.65
| Professional | | $36.10 | $47.55 | $52.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.55 / $50.40 / $109.86
| Professional | | $47.55 | $50.40 | $109.86 |