- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.90 / $42.90 / $42.90
| Facility | | $42.90 | $42.90 | $42.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.90 / $42.90 / $47.19
| Professional | | $42.90 | $42.90 | $47.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.32 / $45.32 / $45.32
| Facility | | $45.32 | $45.32 | $45.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.32 / $45.32 / $45.32
| Professional | | $45.32 | $45.32 | $45.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.11 / $49.98 / $212.00
| Facility | | $47.11 | $49.98 | $212.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.11 / $47.11 / $47.11
| Professional | | $47.11 | $47.11 | $47.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.16 / $51.41 / $332.00
| Facility | | $31.16 | $51.41 | $332.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.39 / $45.42 / $45.42
| Professional | | $37.39 | $45.42 | $45.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.11 / $49.98 / $597.00
| Facility | | $47.11 | $49.98 | $597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.11 / $52.00 / $52.00
| Professional | | $47.11 | $52.00 | $52.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.47 / $50.47 / $73.37
| Professional | | $50.47 | $50.47 | $73.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.74 / $45.74 / $45.74
| Facility | | $45.74 | $45.74 | $45.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.74 / $45.74 / $45.74
| Professional | | $45.74 | $45.74 | $45.74 |