- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.61 / $33.61 / $33.61
| Professional | | $33.61 | $33.61 | $33.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.20 / $223.20 / $223.20
| Facility | | $223.20 | $223.20 | $223.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $235.10
| Facility | | $45.37 | $45.37 | $235.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $31.33 / $39.24
| Professional | | $13.38 | $31.33 | $39.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $235.10
| Facility | | $45.37 | $45.37 | $235.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $31.33 / $39.24
| Professional | | $13.38 | $31.33 | $39.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $16.27 / $37.95
| Professional | | $12.60 | $16.27 | $37.95 |