- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.23 / $29.23 / $29.23
| Professional | | $29.23 | $29.23 | $29.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.85 / $285.52 / $297.55
| Facility | | $129.85 | $285.52 | $297.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.43 / $100.43 / $100.43
| Facility | | $100.43 | $100.43 | $100.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $26.50 / $86.21
| Professional | | $11.66 | $26.50 | $86.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.43 / $100.43 / $100.43
| Facility | | $100.43 | $100.43 | $100.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.66 / $26.50 / $86.21
| Professional | | $11.66 | $26.50 | $86.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.05 / $23.41 / $37.63
| Professional | | $14.05 | $23.41 | $37.63 |