- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.84 / $64.48 / $64.48
| Professional | | $35.84 | $64.48 | $64.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $63.70
| Facility | | $57.54 | $57.54 | $63.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.84 / $57.54 / $102.75
| Professional | | $49.84 | $57.54 | $102.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.54 / $64.48 / $95.53
| Facility | | $36.54 | $64.48 | $95.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.00 / $82.00 / $82.00
| Professional | | $82.00 | $82.00 | $82.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.50 / $52.78 / $99.49
| Professional | | $36.50 | $52.78 | $99.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.62 / $413.01 / $413.01
| Facility | | $100.62 | $413.01 | $413.01 |