- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.50 / $33.50 / $41.87
| Professional | | $33.50 | $33.50 | $41.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.58 / $302.58 / $302.58
| Facility | | $302.58 | $302.58 | $302.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $34.11 / $173.28
| Professional | | $27.30 | $34.11 | $173.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.43 / $31.97 / $45.26
| Facility | | $20.43 | $31.97 | $45.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.00 / $31.97 / $44.63
| Professional | | $23.00 | $31.97 | $44.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.72 / $32.86 / $62.97
| Professional | | $28.72 | $32.86 | $62.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.30 / $34.44 / $40.94
| Professional | | $27.30 | $34.44 | $40.94 |