- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.74 / $32.74 / $32.74
| Professional | | $32.74 | $32.74 | $32.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.43 / $249.76 / $333.64
| Facility | | $145.43 | $249.76 | $333.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.39 / $31.39 / $262.47
| Facility | | $31.39 | $31.39 | $262.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $21.48 / $29.76
| Professional | | $13.03 | $21.48 | $29.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.39 / $31.39 / $262.47
| Facility | | $31.39 | $31.39 | $262.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $21.48 / $29.76
| Professional | | $13.03 | $21.48 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.25 / $11.25 / $26.25
| Professional | | $11.25 | $11.25 | $26.25 |