- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.54 / $30.54 / $30.54
| Professional | | $30.54 | $30.54 | $30.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.08 / $210.08 / $269.05
| Facility | | $210.08 | $210.08 | $269.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $45.37
| Facility | | $45.37 | $45.37 | $45.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $28.60 / $39.24
| Professional | | $11.83 | $28.60 | $39.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $45.37
| Facility | | $45.37 | $45.37 | $45.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $28.60 / $39.24
| Professional | | $11.83 | $28.60 | $39.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $16.27 / $37.89
| Professional | | $12.60 | $16.27 | $37.89 |