- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.35 / $73.06 / $142.72
| Facility | | $32.35 | $73.06 | $142.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.35 / $32.35 / $32.35
| Professional | | $32.35 | $32.35 | $32.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.54 / $36.54 / $37.61
| Professional | | $36.54 | $36.54 | $37.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.25 / $35.25 / $35.25
| Facility | | $35.25 | $35.25 | $35.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.91 / $57.91 / $57.91
| Professional | | $57.91 | $57.91 | $57.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.16 / $35.56 / $45.14
| Professional | | $31.16 | $35.56 | $45.14 |