- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.31 / $23.31 / $23.31
| Professional | | $23.31 | $23.31 | $23.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.56 / $227.02 / $280.38
| Facility | | $103.56 | $227.02 | $280.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.35 / $22.35 / $295.30
| Facility | | $22.35 | $22.35 | $295.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.26 / $15.28 / $21.20
| Professional | | $9.26 | $15.28 | $21.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.35 / $22.35 / $295.30
| Facility | | $22.35 | $22.35 | $295.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.26 / $15.28 / $21.20
| Professional | | $9.26 | $15.28 | $21.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.02 / $11.20 / $26.12
| Professional | | $8.02 | $11.20 | $26.12 |