- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.72 / $28.72 / $28.72
| Professional | | $28.72 | $28.72 | $28.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.61 / $280.33 / $292.37
| Facility | | $127.61 | $280.33 | $292.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.53 / $27.53 / $27.53
| Facility | | $27.53 | $27.53 | $27.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $19.00 / $26.09
| Professional | | $11.32 | $19.00 | $26.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.53 / $27.53 / $27.53
| Facility | | $27.53 | $27.53 | $27.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $19.00 / $26.09
| Professional | | $11.32 | $19.00 | $26.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.19 / $13.80 / $32.20
| Professional | | $7.19 | $13.80 | $32.20 |