- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.03 / $30.03 / $30.03
| Professional | | $30.03 | $30.03 | $30.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.43 / $292.37 / $306.13
| Facility | | $133.43 | $292.37 | $306.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.97 / $22.97 / $22.97
| Professional | | $22.97 | $22.97 | $22.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.44 / $38.44 / $38.44
| Facility | | $38.44 | $38.44 | $38.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $26.43 / $33.04
| Professional | | $12.00 | $26.43 | $33.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.44 / $38.44 / $38.44
| Facility | | $38.44 | $38.44 | $38.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.00 / $26.43 / $33.04
| Professional | | $12.00 | $26.43 | $33.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.78 / $14.43 / $33.67
| Professional | | $13.78 | $14.43 | $33.67 |