- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.29 / $40.29 / $40.29
| Facility | | $40.29 | $40.29 | $40.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.20 / $40.25 / $41.66
| Professional | | $33.20 | $40.25 | $41.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.69 / $38.69 / $38.69
| Professional | | $38.69 | $38.69 | $38.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.20 / $40.13 / $54.14
| Facility | | $33.20 | $40.13 | $54.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.38 / $73.59 / $84.10
| Professional | | $69.38 | $73.59 | $84.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $78.56
| Professional | | $30.00 | $55.00 | $78.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.29 / $61.36 / $62.69
| Professional | | $53.29 | $61.36 | $62.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.08 / $63.21 / $133.10
| Professional | | $44.08 | $63.21 | $133.10 |