- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.36 / $55.00 / $55.00
| Professional | | $28.36 | $55.00 | $55.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.80 / $46.24 / $83.60
| Facility | | $12.80 | $46.24 | $83.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.60 / $12.80 / $17.44
| Professional | | $9.60 | $12.80 | $17.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.60 / $12.60 / $12.60
| Facility | | $12.60 | $12.60 | $12.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.71 / $10.71 / $12.60
| Professional | | $10.71 | $10.71 | $12.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.36 / $30.54 / $78.65
| Facility | | $28.36 | $30.54 | $78.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $13.25 / $22.08
| Professional | | $13.25 | $13.25 | $22.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.25 / $13.25 / $22.08
| Professional | | $13.25 | $13.25 | $22.08 |