- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.04 / $33.04 / $33.04
| Professional | | $33.04 | $33.04 | $33.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.80 / $321.61 / $337.10
| Facility | | $146.80 | $321.61 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.22 / $35.22 / $35.22
| Facility | | $35.22 | $35.22 | $35.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $24.37 / $30.46
| Professional | | $13.20 | $24.37 | $30.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.22 / $35.22 / $35.22
| Facility | | $35.22 | $35.22 | $35.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.19 / $15.66 / $30.46
| Professional | | $15.19 | $15.66 | $30.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.63 / $15.88 / $37.04
| Professional | | $12.63 | $15.88 | $37.04 |