- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.35 / $32.35 / $32.35
| Professional | | $32.35 | $32.35 | $32.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.75 / $314.74 / $330.22
| Facility | | $143.75 | $314.74 | $330.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.03 / $31.03 / $31.03
| Facility | | $31.03 | $31.03 | $31.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $21.06 / $29.36
| Professional | | $12.86 | $21.06 | $29.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.03 / $31.03 / $31.03
| Facility | | $31.03 | $31.03 | $31.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.86 / $21.06 / $29.36
| Professional | | $12.86 | $21.06 | $29.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.12 / $15.55 / $36.27
| Professional | | $11.12 | $15.55 | $36.27 |