- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $107.15 / $117.49
| Facility | | $57.54 | $107.15 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $45.71 / $107.15
| Professional | | $38.02 | $45.71 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Facility | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.39 / $38.02 / $43.65
| Facility | | $22.39 | $38.02 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $38.02 / $69.18
| Professional | | $21.38 | $38.02 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.55 / $52.48 / $57.54
| Facility | | $24.55 | $52.48 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $26.30 / $63.10
| Professional | | $14.13 | $26.30 | $63.10 |