- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.41 / $25.41 / $25.41
| Professional | | $25.41 | $25.41 | $25.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.84 / $247.65 / $259.70
| Facility | | $112.84 | $247.65 | $259.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.42 / $26.42 / $26.42
| Facility | | $26.42 | $26.42 | $26.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.11 / $18.17 / $22.83
| Professional | | $10.11 | $18.17 | $22.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.42 / $26.42 / $26.42
| Facility | | $26.42 | $26.42 | $26.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.11 / $18.17 / $22.83
| Professional | | $10.11 | $18.17 | $22.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.47 / $12.20 / $28.48
| Professional | | $9.47 | $12.20 | $28.48 |