- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.22 / $54.48 / $54.48
| Professional | | $39.22 | $54.48 | $54.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.81 / $103.42 / $191.71
| Facility | | $79.81 | $103.42 | $191.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.09 / $52.41 / $52.41
| Professional | | $48.09 | $52.41 | $52.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.03 / $57.03 / $57.03
| Facility | | $57.03 | $57.03 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.63 / $41.63 / $57.03
| Professional | | $41.63 | $41.63 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.67 / $72.67 / $72.67
| Professional | | $72.67 | $72.67 | $72.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.54 / $54.48 / $54.48
| Professional | | $50.54 | $54.48 | $54.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.58 / $44.78 / $102.96
| Professional | | $31.58 | $44.78 | $102.96 |