- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $74.13
| Facility | | $56.23 | $56.23 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $83.18 / $120.23
| Professional | | $54.95 | $83.18 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $46.77 / $57.54
| Professional | | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.13 / $83.18 / $120.23
| Facility | | $74.13 | $83.18 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |