- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.01 / $30.01 / $30.01
| Professional | | $30.01 | $30.01 | $30.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.32 / $306.13 / $463.80
| Facility | | $133.32 | $306.13 | $463.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Facility | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $27.32 / $39.24
| Professional | | $11.83 | $27.32 | $39.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Facility | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $27.32 / $39.24
| Professional | | $11.83 | $27.32 | $39.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.92 / $16.38 / $38.22
| Professional | | $11.92 | $16.38 | $38.22 |