- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.53 / $29.53 / $51.68
| Facility | | $29.53 | $29.53 | $51.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.26 / $29.53 / $31.09
| Professional | | $26.26 | $29.53 | $31.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.70 / $18.70 / $18.70
| Professional | | $18.70 | $18.70 | $18.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.45 / $158.61 / $174.09
| Facility | | $66.45 | $158.61 | $174.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.43 / $32.43 / $32.43
| Facility | | $31.43 | $32.43 | $32.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.76 / $37.47 / $67.39
| Professional | | $11.76 | $37.47 | $67.39 |