- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.63 / $35.63 / $35.63
| Professional | | $35.63 | $35.63 | $35.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.28 / $347.43 / $362.90
| Facility | | $158.28 | $347.43 | $362.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.17 / $34.17 / $34.17
| Facility | | $34.17 | $34.17 | $34.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.54 / $32.21
| Professional | | $14.06 | $23.54 | $32.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.17 / $34.17 / $34.17
| Facility | | $34.17 | $34.17 | $34.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.54 / $32.21
| Professional | | $14.06 | $23.54 | $32.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.25 / $17.12 / $39.94
| Professional | | $12.25 | $17.12 | $39.94 |