- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.46 / $32.46 / $32.46
| Professional | | $32.46 | $32.46 | $32.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.24 / $316.45 / $330.22
| Facility | | $144.24 | $316.45 | $330.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.35 / $34.35 / $34.35
| Facility | | $34.35 | $34.35 | $34.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $23.54 / $32.61
| Professional | | $14.23 | $23.54 | $32.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.35 / $34.35 / $34.35
| Facility | | $34.35 | $34.35 | $34.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $23.54 / $32.61
| Professional | | $14.23 | $23.54 | $32.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.31 / $15.60 / $36.40
| Professional | | $12.31 | $15.60 | $36.40 |