- 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 / $216.57 / $292.37
| Facility | | $127.61 | $216.57 | $292.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.50 / $39.50 / $39.50
| Facility | | $39.50 | $39.50 | $39.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $26.09 / $34.07
| Professional | | $11.32 | $26.09 | $34.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.50 / $39.50 / $39.50
| Facility | | $39.50 | $39.50 | $39.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $26.09 / $34.07
| Professional | | $11.32 | $26.09 | $34.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.80 / $14.16 / $33.04
| Professional | | $13.80 | $14.16 | $33.04 |