- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.82 / $46.60 / $46.60
| Professional | | $23.82 | $46.60 | $46.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.60 / $44.42 / $44.42
| Facility | | $41.60 | $44.42 | $44.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.76 / $44.42 / $77.63
| Professional | | $37.76 | $44.42 | $77.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.74 / $46.60 / $59.45
| Facility | | $22.74 | $46.60 | $59.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $51.00 / $51.00
| Professional | | $51.00 | $51.00 | $51.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.74 / $33.72 / $56.34
| Professional | | $22.74 | $33.72 | $56.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $317.54 / $317.54
| Facility | | $100.00 | $317.54 | $317.54 |