- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $28.18 / $35.48
| Professional | | $25.12 | $28.18 | $35.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $31.62
| Facility | | $15.85 | $15.85 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Professional | | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15.85 / $17.38 / $33.88
| Facility | | $15.85 | $17.38 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Professional | | $26.92 | $26.92 | $26.92 |