- 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
- $208.48 / $208.48 / $208.48
| Facility | | $208.48 | $208.48 | $208.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $219.60
| Facility | | $45.37 | $45.37 | $219.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.39 / $31.39 / $39.24
| Professional | | $31.39 | $31.39 | $39.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.37 / $45.37 / $219.60
| Facility | | $45.37 | $45.37 | $219.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.62 / $31.39 / $39.24
| Professional | | $17.62 | $31.39 | $39.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $16.27 / $37.95
| Professional | | $12.60 | $16.27 | $37.95 |