- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.75 / $36.75 / $36.75
| Professional | | $36.75 | $36.75 | $36.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.33 / $357.73 / $374.94
| Facility | | $163.33 | $357.73 | $374.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.28 / $35.28 / $35.28
| Facility | | $35.28 | $35.28 | $35.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.58 / $24.37 / $33.43
| Professional | | $14.58 | $24.37 | $33.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.28 / $35.28 / $35.28
| Facility | | $35.28 | $35.28 | $35.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.58 / $24.37 / $33.43
| Professional | | $14.58 | $24.37 | $33.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.44 / $17.66 / $57.11
| Professional | | $12.44 | $17.66 | $57.11 |