- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.77 / $38.77 / $38.77
| Facility | | $38.77 | $38.77 | $38.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.87 / $38.77 / $40.03
| Professional | | $31.87 | $38.77 | $40.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.48 / $86.34 / $101.96
| Professional | | $78.48 | $86.34 | $101.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $44.31 / $55.72
| Professional | | $36.31 | $44.31 | $55.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.13 / $38.77 / $81.02
| Facility | | $37.13 | $38.77 | $81.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.57 / $71.12 / $340.83
| Professional | | $37.57 | $71.12 | $340.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.70 / $70.27 / $83.68
| Professional | | $39.70 | $70.27 | $83.68 |