- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.77 / $38.77 / $38.77
| Facility | | $38.77 | $38.77 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.87 / $79.81 / $190.93
| Professional | | $29.87 | $79.81 | $190.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.33 / $33.34 / $47.04
| Professional | | $28.33 | $33.34 | $47.04 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $42.50 / $50.01 / $70.56
| Professional | 50 | $42.50 | $50.01 | $70.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.93 / $46.51 / $114.47
| Professional | | $30.93 | $46.51 | $114.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.09 / $41.22 / $73.16
| Professional | | $30.09 | $41.22 | $73.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.77 / $38.77 / $38.77
| Facility | | $38.77 | $38.77 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.87 / $53.55 / $203.54
| Professional | | $29.87 | $53.55 | $203.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.03 / $73.41 / $252.96
| Professional | | $33.03 | $73.41 | $252.96 |