- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.01 / $23.01 / $23.01
| Professional | | $23.01 | $23.01 | $23.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.26 / $121.18 / $233.90
| Facility | | $102.26 | $121.18 | $233.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.07 / $22.07 / $127.70
| Facility | | $22.07 | $22.07 | $127.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.09 / $15.28 / $20.79
| Professional | | $9.09 | $15.28 | $20.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.07 / $22.07 / $127.70
| Facility | | $22.07 | $22.07 | $127.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.48 / $15.28 / $20.79
| Professional | | $5.48 | $15.28 | $20.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.76 / $11.06 / $25.80
| Professional | | $5.76 | $11.06 | $25.80 |