- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.36 / $37.36 / $37.36
| Professional | | $37.36 | $37.36 | $37.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.02 / $294.11 / $380.08
| Facility | | $166.02 | $294.11 | $380.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.43 / $26.43 / $26.43
| Professional | | $26.43 | $26.43 | $26.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.84 / $35.84 / $309.80
| Facility | | $35.84 | $35.84 | $309.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $24.37 / $33.84
| Professional | | $14.92 | $24.37 | $33.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.84 / $35.84 / $309.80
| Facility | | $35.84 | $35.84 | $309.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.92 / $24.37 / $33.84
| Professional | | $14.92 | $24.37 | $33.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.55 / $17.95 / $41.89
| Professional | | $11.55 | $17.95 | $41.89 |