- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.52 / $28.52 / $28.52
| Professional | | $28.52 | $28.52 | $28.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.74 / $126.71 / $290.62
| Facility | | $100.74 | $126.71 | $290.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.35 / $27.35 / $106.10
| Facility | | $27.35 | $27.35 | $106.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $19.00 / $25.69
| Professional | | $11.32 | $19.00 | $25.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.35 / $27.35 / $106.10
| Facility | | $27.35 | $27.35 | $106.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.32 / $19.00 / $25.69
| Professional | | $11.32 | $19.00 | $25.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.35 / $13.70 / $31.96
| Professional | | $7.35 | $13.70 | $31.96 |