- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.72 / $43.72 / $43.72
| Professional | | $43.72 | $43.72 | $43.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.28 / $426.51 / $445.46
| Facility | | $194.28 | $426.51 | $445.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.67 / $48.67 / $48.67
| Facility | | $48.67 | $48.67 | $48.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $33.45 / $41.82
| Professional | | $17.32 | $33.45 | $41.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.67 / $48.67 / $48.67
| Facility | | $48.67 | $48.67 | $48.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.32 / $33.45 / $41.82
| Professional | | $17.32 | $33.45 | $41.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.70 / $21.01 / $49.01
| Professional | | $12.70 | $21.01 | $49.01 |