- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.83 / $33.83 / $33.83
| Facility | | $33.83 | $33.83 | $33.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.92 / $31.92 / $33.83
| Professional | | $31.92 | $31.92 | $33.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.48 / $51.41 / $52.68
| Professional | | $43.48 | $51.41 | $52.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.25 / $53.78 / $67.63
| Professional | | $53.25 | $53.78 | $67.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.63 / $33.83 / $214.06
| Facility | | $13.63 | $33.83 | $214.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.53 / $22.75 / $37.04
| Professional | | $18.53 | $22.75 | $37.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.66 / $22.75 / $37.04
| Professional | | $13.66 | $22.75 | $37.04 |