- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.03 / $27.03 / $27.03
| Professional | | $27.03 | $27.03 | $27.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.12 / $263.14 / $275.17
| Facility | | $120.12 | $263.14 | $275.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.93 / $25.93 / $25.93
| Facility | | $25.93 | $25.93 | $25.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $17.76 / $24.46
| Professional | | $10.80 | $17.76 | $24.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.93 / $25.93 / $25.93
| Facility | | $25.93 | $25.93 | $25.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.80 / $17.76 / $24.46
| Professional | | $10.80 | $17.76 | $24.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.77 / $12.98 / $30.30
| Professional | | $6.77 | $12.98 | $30.30 |