- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.13 / $52.46 / $102.86
| Facility | | $42.13 | $52.46 | $102.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.13 / $42.13 / $42.13
| Professional | | $42.13 | $42.13 | $42.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.88 / $16.84 / $22.66
| Facility | | $13.88 | $16.84 | $22.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.11 / $31.71 / $33.36
| Professional | | $26.11 | $31.71 | $33.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.45 / $43.46 / $161.22
| Facility | | $40.45 | $43.46 | $161.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.10 / $59.10 / $73.88
| Professional | | $59.10 | $59.10 | $73.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.77 / $19.57 / $44.56
| Professional | | $15.77 | $19.57 | $44.56 |