- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.64 / $67.72 / $153.76
| Facility | | $47.64 | $67.72 | $153.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.00 / $47.64 / $54.00
| Professional | | $42.00 | $47.64 | $54.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.44 / $50.10 / $50.10
| Facility | | $35.44 | $50.10 | $50.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.10 / $50.10 / $50.10
| Professional | | $50.10 | $50.10 | $50.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.73 / $49.70 / $53.53
| Professional | | $44.73 | $49.70 | $53.53 |