- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.51 / $22.51 / $22.51
| Professional | | $22.51 | $22.51 | $22.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.36 / $819.92 / $1,109.10
| Facility | | $655.36 | $819.92 | $1,109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $21.00 / $21.00
| Professional | | $21.00 | $21.00 | $21.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.00 / $77.00 / $165.00
| Facility | | $77.00 | $77.00 | $165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.89 / $72.00 / $165.00
| Professional | | $20.89 | $72.00 | $165.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $75.00 / $75.00
| Facility | | $23.64 | $75.00 | $75.00 |