- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.06 / $12.06 / $12.06
| Professional | | $12.06 | $12.06 | $12.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.76 / $34.19 / $66.25
| Facility | | $18.76 | $34.19 | $66.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $3.50 / $3.50
| Professional | | $3.50 | $3.50 | $3.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.82 / $59.76 / $103.46
| Facility | | $20.82 | $59.76 | $103.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |