- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.28 / $52.38 / $101.47
| Facility | | $42.28 | $52.38 | $101.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $42.28
| Professional | | $42.28 | $42.28 | $42.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.48 / $29.04 / $29.33
| Facility | | $27.48 | $29.04 | $29.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $48.57 / $60.71
| Professional | | $42.28 | $48.57 | $60.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $200.83
| Facility | | $42.28 | $42.28 | $200.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.73 / $17.76 / $42.17
| Professional | | $17.73 | $17.76 | $42.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.73 / $17.76 / $25.37
| Professional | | $17.73 | $17.76 | $25.37 |