- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.33 / $33.67 / $47.83
| Professional | | $25.33 | $33.67 | $47.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.12 / $72.83 / $72.83
| Professional | | $71.12 | $72.83 | $72.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.22 / $26.22 / $26.22
| Professional | | $26.22 | $26.22 | $26.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.87 / $47.87 / $47.87
| Professional | | $47.87 | $47.87 | $47.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.33 / $33.67 / $47.83
| Professional | | $25.33 | $33.67 | $47.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.92 / $29.28 / $67.31
| Professional | | $22.92 | $29.28 | $67.31 |