- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $38.02 / $109.65
| Professional | | $28.84 | $38.02 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $141.25 / $165.96
| Facility | | $102.33 | $141.25 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $45.71 / $75.86
| Professional | | $34.67 | $45.71 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.74 / $40.74 / $48.98
| Facility | | $40.74 | $40.74 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $35.48 / $48.98
| Professional | | $35.48 | $35.48 | $48.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $37.15 / $83.18
| Facility | | $30.20 | $37.15 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $38.02 / $58.88
| Professional | | $30.20 | $38.02 | $58.88 |