- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.86 / $32.86 / $35.11
| Facility | | $32.86 | $32.86 | $35.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.77 / $26.01 / $35.11
| Professional | | $22.77 | $26.01 | $35.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.12 / $204.46 / $204.46
| Facility | | $177.12 | $204.46 | $204.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.13 / $26.03 / $28.84
| Professional | | $22.13 | $26.03 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.41 / $341.41 / $341.41
| Facility | | $341.41 | $341.41 | $341.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.70 / $24.70 / $29.42
| Professional | | $24.70 | $24.70 | $29.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.77 / $37.02 / $49.36
| Professional | | $27.77 | $37.02 | $49.36 |