- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.01 / $33.01 / $33.01
| Professional | | $33.01 | $33.01 | $33.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.63 / $321.61 / $337.10
| Facility | | $146.63 | $321.61 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.84 / $33.84 / $33.84
| Facility | | $33.84 | $33.84 | $33.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.54 / $31.80
| Professional | | $14.06 | $23.54 | $31.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.84 / $33.84 / $33.84
| Facility | | $33.84 | $33.84 | $33.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.54 / $31.80
| Professional | | $14.06 | $23.54 | $31.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.13 / $15.85 / $36.99
| Professional | | $12.13 | $15.85 | $36.99 |