- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.57 / $30.57 / $30.57
| Professional | | $30.57 | $30.57 | $30.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.81 / $297.55 / $311.32
| Facility | | $135.81 | $297.55 | $311.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.64 / $21.64 / $21.64
| Professional | | $21.64 | $21.64 | $21.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.97 / $29.97 / $29.97
| Facility | | $29.97 | $29.97 | $29.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $20.65 / $27.72
| Professional | | $12.17 | $20.65 | $27.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.97 / $29.97 / $29.97
| Facility | | $29.97 | $29.97 | $29.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $20.65 / $27.72
| Professional | | $12.17 | $20.65 | $27.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $14.68 / $34.26
| Professional | | $10.74 | $14.68 | $34.26 |