- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.94 / $24.94 / $24.94
| Professional | | $24.94 | $24.94 | $24.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.81 / $254.54 / $506.02
| Facility | | $110.81 | $254.54 | $506.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.65 / $25.65 / $425.10
| Facility | | $25.65 | $25.65 | $425.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.63 / $17.35 / $24.06
| Professional | | $10.63 | $17.35 | $24.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.65 / $25.65 / $425.10
| Facility | | $25.65 | $25.65 | $425.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.63 / $17.35 / $24.06
| Professional | | $10.63 | $17.35 | $24.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.19 / $11.98 / $32.10
| Professional | | $9.19 | $11.98 | $32.10 |