- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.51 / $24.51 / $24.51
| Professional | | $24.51 | $24.51 | $24.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.84 / $239.06 / $249.38
| Facility | | $108.84 | $239.06 | $249.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.51 / $23.51 / $23.51
| Facility | | $23.51 | $23.51 | $23.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $16.11 / $22.02
| Professional | | $9.77 | $16.11 | $22.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.51 / $23.51 / $23.51
| Facility | | $23.51 | $23.51 | $23.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $16.11 / $22.02
| Professional | | $9.77 | $16.11 | $22.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.43 / $11.77 / $27.47
| Professional | | $8.43 | $11.77 | $27.47 |