- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.58 / $36.58 / $36.58
| Professional | | $36.58 | $36.58 | $36.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.55 / $356.00 / $373.22
| Facility | | $162.55 | $356.00 | $373.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.78 / $32.78 / $32.78
| Facility | | $32.78 | $32.78 | $32.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.58 / $22.72 / $33.02
| Professional | | $14.58 | $22.72 | $33.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.78 / $32.78 / $32.78
| Facility | | $32.78 | $32.78 | $32.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.58 / $22.72 / $33.02
| Professional | | $14.58 | $22.72 | $33.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.56 / $17.57 / $47.09
| Professional | | $8.56 | $17.57 | $47.09 |