- 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
- $146.85 / $321.61 / $337.10
| Facility | | $146.85 | $321.61 | $337.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.67 / $31.67 / $31.67
| Facility | | $31.67 | $31.67 | $31.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $21.89 / $29.76
| Professional | | $13.20 | $21.89 | $29.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.67 / $31.67 / $31.67
| Facility | | $31.67 | $31.67 | $31.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.20 / $21.89 / $29.76
| Professional | | $13.20 | $21.89 | $29.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.27 / $15.88 / $37.04
| Professional | | $8.27 | $15.88 | $37.04 |