- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $20.30 / $20.30
| Professional | | $20.30 | $20.30 | $20.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.19 / $197.77 / $206.38
| Facility | | $90.19 | $197.77 | $206.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.35 / $21.35 / $21.35
| Facility | | $21.35 | $21.35 | $21.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $14.46 / $18.35
| Professional | | $8.06 | $14.46 | $18.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.35 / $21.35 / $21.35
| Facility | | $21.35 | $21.35 | $21.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.06 / $14.46 / $18.35
| Professional | | $8.06 | $14.46 | $18.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.57 / $10.19 / $31.54
| Professional | | $5.57 | $10.19 | $31.54 |