- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.05 / $54.05 / $54.05
| Professional | | $54.05 | $54.05 | $54.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.25 / $240.18 / $550.35
| Facility | | $187.25 | $240.18 | $550.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.86 / $51.86 / $197.20
| Facility | | $51.86 | $51.86 | $197.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.43 / $35.52 / $48.93
| Professional | | $21.43 | $35.52 | $48.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.86 / $51.86 / $197.20
| Facility | | $51.86 | $51.86 | $197.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.43 / $35.52 / $48.93
| Professional | | $21.43 | $35.52 | $48.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.59 / $25.97 / $60.59
| Professional | | $18.59 | $25.97 | $60.59 |