- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.77 / $32.77 / $32.77
| Facility | | $32.77 | $32.77 | $32.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.77 / $32.77 / $32.77
| Professional | | $32.77 | $32.77 | $32.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.54 / $135.54 / $135.54
| Facility | | $135.54 | $135.54 | $135.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.25 / $32.77 / $190.76
| Facility | | $29.25 | $32.77 | $190.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.65 / $49.39 / $311.68
| Professional | | $35.65 | $49.39 | $311.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.36 / $47.35 / $68.94
| Professional | | $34.36 | $47.35 | $68.94 |