- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.22 / $33.22 / $33.22
| Professional | | $33.22 | $33.22 | $33.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.59 / $267.83 / $338.81
| Facility | | $147.59 | $267.83 | $338.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.88 / $31.88 / $282.10
| Facility | | $31.88 | $31.88 | $282.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $21.89 / $30.17
| Professional | | $13.20 | $21.89 | $30.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.88 / $31.88 / $282.10
| Facility | | $31.88 | $31.88 | $282.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $21.89 / $30.17
| Professional | | $13.20 | $21.89 | $30.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.32 / $16.67 / $51.62
| Professional | | $8.32 | $16.67 | $51.62 |