- 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
- $84.94 / $146.69 / $337.10
| Facility | | $84.94 | $146.69 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $88.02
| Facility | | $32.34 | $32.34 | $88.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.03 / $22.30 / $29.76
| Professional | | $13.03 | $22.30 | $29.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $88.02
| Facility | | $32.34 | $32.34 | $88.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.20 / $22.30 / $29.76
| Professional | | $6.20 | $22.30 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.59 / $26.43 / $60.00
| Professional | | $11.59 | $26.43 | $60.00 |