- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.02 / $33.02 / $33.02
| Professional | | $33.02 | $33.02 | $33.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.69 / $321.61 / $337.10
| Facility | | $146.69 | $321.61 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.65 / $31.65 / $31.65
| Facility | | $31.65 | $31.65 | $31.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $21.48 / $29.76
| Professional | | $13.03 | $21.48 | $29.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.65 / $31.65 / $31.65
| Facility | | $31.65 | $31.65 | $31.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.42 / $21.48 / $29.76
| Professional | | $12.42 | $21.48 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.35 / $16.57 / $42.49
| Professional | | $11.35 | $16.57 | $42.49 |