- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $52.48 / $93.33
| Professional | | $44.67 | $52.48 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $120.23
| Facility | | $60.26 | $60.26 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $95.50
| Professional | | $43.65 | $43.65 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.31 / $47.86 / $87.10
| Facility | | $36.31 | $47.86 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $47.86 / $72.44
| Professional | | $43.65 | $47.86 | $72.44 |