- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.65 / $46.77 / $46.77
| Professional | | $33.65 | $46.77 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.54 / $88.80 / $164.60
| Facility | | $68.54 | $88.80 | $164.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.28 / $43.04 / $43.04
| Professional | | $40.28 | $43.04 | $43.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.72 / $36.72 / $56.63
| Facility | | $36.72 | $36.72 | $56.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.81 / $26.81 / $36.72
| Professional | | $26.81 | $26.81 | $36.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.39 / $62.39 / $62.39
| Professional | | $62.39 | $62.39 | $62.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.38 / $46.77 / $46.77
| Professional | | $43.38 | $46.77 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.63 / $38.44 / $88.39
| Professional | | $25.63 | $38.44 | $88.39 |