- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.38 / $33.38 / $33.38
| Professional | | $33.38 | $33.38 | $33.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.32 / $325.06 / $340.53
| Facility | | $148.32 | $325.06 | $340.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.63 / $23.63 / $23.63
| Professional | | $23.63 | $23.63 | $23.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.61 / $35.61 / $35.61
| Facility | | $35.61 | $35.61 | $35.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $24.37 / $30.46
| Professional | | $13.20 | $24.37 | $30.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.61 / $35.61 / $35.61
| Facility | | $35.61 | $35.61 | $35.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.36 / $15.66 / $30.46
| Professional | | $15.36 | $15.66 | $30.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.28 / $16.04 / $37.42
| Professional | | $9.28 | $16.04 | $37.42 |