- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.24 / $35.24 / $35.24
| Professional | | $35.24 | $35.24 | $35.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.58 / $310.94 / $359.44
| Facility | | $156.58 | $310.94 | $359.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.81 / $33.81 / $33.81
| Facility | | $33.81 | $33.81 | $33.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.13 / $31.80
| Professional | | $14.06 | $23.13 | $31.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.81 / $33.81 / $33.81
| Facility | | $33.81 | $33.81 | $33.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.06 / $23.13 / $31.80
| Professional | | $14.06 | $23.13 | $31.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.78 / $16.93 / $39.51
| Professional | | $10.78 | $16.93 | $39.51 |