- 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 / $292.37 / $306.13
| Facility | | $133.32 | $292.37 | $306.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.01 / $45.01 / $45.01
| Facility | | $45.01 | $45.01 | $45.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $27.32 / $38.72
| Professional | | $11.83 | $27.32 | $38.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.01 / $45.01 / $45.01
| Facility | | $45.01 | $45.01 | $45.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.83 / $27.32 / $38.72
| Professional | | $11.83 | $27.32 | $38.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.60 / $14.41 / $37.65
| Professional | | $12.60 | $14.41 | $37.65 |