- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.74 / $46.74 / $46.74
| Professional | | $46.74 | $46.74 | $46.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.64 / $308.33 / $476.40
| Facility | | $207.64 | $308.33 | $476.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.08 / $33.08 / $33.08
| Professional | | $33.08 | $33.08 | $33.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.83 / $44.83 / $324.70
| Facility | | $44.83 | $44.83 | $324.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.52 / $30.98 / $42.40
| Professional | | $18.52 | $30.98 | $42.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.83 / $44.83 / $324.70
| Facility | | $44.83 | $44.83 | $324.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.52 / $30.98 / $42.40
| Professional | | $18.52 | $30.98 | $42.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.75 / $16.07 / $52.37
| Professional | | $15.75 | $16.07 | $52.37 |