- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.90 / $36.90 / $94.88
| Facility | | $36.90 | $36.90 | $94.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.90 / $36.90 / $49.55
| Professional | | $36.90 | $36.90 | $49.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.63 / $106.21 / $119.19
| Professional | | $87.63 | $106.21 | $119.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.71 / $61.32 / $77.09
| Professional | | $60.71 | $61.32 | $77.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.90 / $62.73 / $250.37
| Facility | | $36.90 | $62.73 | $250.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.14 / $52.71 / $89.61
| Professional | | $22.14 | $52.71 | $89.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.14 / $53.76 / $73.79
| Professional | | $22.14 | $53.76 | $73.79 |