- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.72 / $29.72 / $29.72
| Professional | | $29.72 | $29.72 | $29.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.08 / $290.62 / $302.70
| Facility | | $132.08 | $290.62 | $302.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.51 / $28.51 / $28.51
| Facility | | $28.51 | $28.51 | $28.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.48 / $26.85 / $47.35
| Professional | | $21.48 | $26.85 | $47.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.51 / $28.51 / $28.51
| Facility | | $28.51 | $28.51 | $28.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.66 / $21.67 / $47.35
| Professional | | $13.66 | $21.67 | $47.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.44 / $14.28 / $33.32
| Professional | | $7.44 | $14.28 | $33.32 |