- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.54 / $30.54 / $30.54
| Professional | | $30.54 | $30.54 | $30.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.64 / $306.64 / $306.64
| Facility | | $306.64 | $306.64 | $306.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $323.00
| Facility | | $30.20 | $30.20 | $323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $20.65 / $28.60
| Professional | | $11.83 | $20.65 | $28.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $323.00
| Facility | | $30.20 | $30.20 | $323.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $20.65 / $28.60
| Professional | | $11.83 | $20.65 | $28.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.44 / $14.78 / $34.47
| Professional | | $9.44 | $14.78 | $34.47 |