- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.57 / $46.47 / $115.73
| Facility | | $30.57 | $46.47 | $115.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.57 / $34.17
| Professional | | $30.00 | $30.57 | $34.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.38 / $23.38 / $23.38
| Facility | | $23.38 | $23.38 | $23.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.71 / $33.71 / $33.71
| Facility | | $33.71 | $33.71 | $33.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.71 / $33.71 / $33.71
| Professional | | $33.71 | $33.71 | $33.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $29.05 / $32.28
| Professional | | $20.00 | $29.05 | $32.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.17 / $35.97 / $40.32
| Professional | | $34.17 | $35.97 | $40.32 |