- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.08 / $36.08 / $36.08
| Professional | | $36.08 | $36.08 | $36.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.25 / $165.92 / $368.05
| Facility | | $160.25 | $165.92 | $368.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.52 / $25.52 / $25.52
| Professional | | $25.52 | $25.52 | $25.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.61 / $34.61 / $174.80
| Facility | | $34.61 | $34.61 | $174.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.40 / $23.95 / $32.61
| Professional | | $14.40 | $23.95 | $32.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.61 / $34.61 / $174.80
| Facility | | $34.61 | $34.61 | $174.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.59 / $16.93 / $32.61
| Professional | | $16.59 | $16.93 | $32.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.02 / $17.32 / $40.45
| Professional | | $9.02 | $17.32 | $40.45 |