- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.78 / $30.78 / $30.78
| Professional | | $30.78 | $30.78 | $30.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.71 / $217.77 / $313.02
| Facility | | $136.71 | $217.77 | $313.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.77 / $21.77 / $21.77
| Professional | | $21.77 | $21.77 | $21.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.51 / $29.51 / $229.40
| Facility | | $29.51 | $29.51 | $229.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $20.65 / $27.72
| Professional | | $12.17 | $20.65 | $27.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.51 / $29.51 / $229.40
| Facility | | $29.51 | $29.51 | $229.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.17 / $20.65 / $27.72
| Professional | | $12.17 | $20.65 | $27.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $14.78 / $34.50
| Professional | | $10.58 | $14.78 | $34.50 |