- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.62 / $29.62 / $29.62
| Professional | | $29.62 | $29.62 | $29.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.65 / $302.70 / $452.40
| Facility | | $131.65 | $302.70 | $452.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.71 / $47.71 / $47.71
| Facility | | $47.71 | $47.71 | $47.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $31.39 / $40.78
| Professional | | $13.72 | $31.39 | $40.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.71 / $47.71 / $47.71
| Facility | | $47.71 | $47.71 | $47.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.72 / $31.39 / $40.78
| Professional | | $13.72 | $31.39 | $40.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.45 / $17.10 / $38.13
| Professional | | $12.45 | $17.10 | $38.13 |