- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $111.85
| Facility | | $43.50 | $43.50 | $111.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $58.41
| Professional | | $43.50 | $43.50 | $58.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.30 / $125.21 / $140.52
| Professional | | $103.30 | $125.21 | $140.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.45 / $72.16 / $90.74
| Professional | | $71.45 | $72.16 | $90.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.50 / $73.95 / $295.17
| Facility | | $43.50 | $73.95 | $295.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.10 / $62.14 / $105.64
| Professional | | $26.10 | $62.14 | $105.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.10 / $31.69 / $90.10
| Professional | | $26.10 | $31.69 | $90.10 |