- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $43.65
| Professional | | $30.20 | $30.20 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.70 / $75.86 / $213.80
| Facility | | $53.70 | $75.86 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Facility | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $19.05 / $43.65
| Professional | | $8.32 | $19.05 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.47 / $10.47 / $10.47
| Facility | | $10.47 | $10.47 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.47 / $18.20 / $66.07
| Professional | | $10.47 | $18.20 | $66.07 |