- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.87 / $36.63 / $52.20
| Professional | | $26.87 | $36.63 | $52.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.15 / $150.15 / $150.15
| Facility | | $150.15 | $150.15 | $150.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $79.48 / $79.48
| Professional | | $77.62 | $79.48 | $79.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.61 / $28.61 / $28.61
| Professional | | $28.61 | $28.61 | $28.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.05 / $52.05 / $52.05
| Professional | | $52.05 | $52.05 | $52.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.87 / $36.63 / $52.20
| Professional | | $26.87 | $36.63 | $52.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.23 / $31.85 / $73.25
| Professional | | $21.23 | $31.85 | $73.25 |