- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.25 / $31.25 / $31.25
| Professional | | $31.25 | $31.25 | $31.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.85 / $304.41 / $350.71
| Facility | | $138.85 | $304.41 | $350.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.10 / $22.10 / $22.10
| Professional | | $22.10 | $22.10 | $22.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.97 / $29.97 / $288.00
| Facility | | $29.97 | $29.97 | $288.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.35 / $20.65 / $28.13
| Professional | | $12.35 | $20.65 | $28.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.97 / $29.97 / $288.00
| Facility | | $29.97 | $29.97 | $288.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.35 / $20.65 / $28.13
| Professional | | $12.35 | $20.65 | $28.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.74 / $15.01 / $35.03
| Professional | | $10.74 | $15.01 | $35.03 |