- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.60 / $78.83 / $259.76
| Facility | | $37.60 | $78.83 | $259.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.05 / $37.36 / $41.10
| Professional | | $31.05 | $37.36 | $41.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.25 / $47.32 / $47.32
| Facility | | $35.25 | $47.32 | $47.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.32 / $47.32 / $47.32
| Professional | | $47.32 | $47.32 | $47.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.36 / $37.36 / $37.36
| Facility | | $37.36 | $37.36 | $37.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.36 / $44.00 / $44.00
| Professional | | $37.36 | $44.00 | $44.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.25 / $42.25 / $49.16
| Professional | | $42.25 | $42.25 | $49.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.36 / $37.36 / $37.36
| Professional | | $36.36 | $37.36 | $37.36 |