- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $26.30 / $26.30
| Professional | | $26.30 | $26.30 | $26.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.87 / $256.25 / $268.29
| Facility | | $116.87 | $256.25 | $268.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.74 / $29.74 / $29.74
| Facility | | $29.74 | $29.74 | $29.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.46 / $20.65 / $25.81
| Professional | | $10.46 | $20.65 | $25.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.74 / $29.74 / $29.74
| Facility | | $29.74 | $29.74 | $29.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.46 / $20.65 / $25.81
| Professional | | $10.46 | $20.65 | $25.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $12.64 / $29.48
| Professional | | $7.76 | $12.64 | $29.48 |