- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.85 / $33.85 / $33.85
| Professional | | $33.85 | $33.85 | $33.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.41 / $330.22 / $345.68
| Facility | | $150.41 | $330.22 | $345.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.47 / $32.47 / $32.47
| Facility | | $32.47 | $32.47 | $32.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $22.30 / $30.58
| Professional | | $13.38 | $22.30 | $30.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.47 / $32.47 / $32.47
| Facility | | $32.47 | $32.47 | $32.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.38 / $22.30 / $30.58
| Professional | | $13.38 | $22.30 | $30.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.50 / $16.27 / $37.95
| Professional | | $10.50 | $16.27 | $37.95 |