- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.03 / $146.71 / $146.71
| Professional | | $20.03 | $146.71 | $146.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.33 / $55.28 / $55.28
| Facility | | $36.33 | $55.28 | $55.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.33 / $55.28 / $55.28
| Professional | | $36.33 | $55.28 | $55.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.94 / $52.65 / $55.28
| Facility | | $25.94 | $52.65 | $55.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.50 / $42.41 / $55.33
| Professional | | $41.50 | $42.41 | $55.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.87 / $26.87 / $29.02
| Facility | | $26.87 | $26.87 | $29.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.98 / $23.21 / $35.53
| Professional | | $20.98 | $23.21 | $35.53 |