- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.77 / $103.61 / $139.61
| Facility | | $36.77 | $103.61 | $139.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.77 / $36.77 / $36.77
| Professional | | $36.77 | $36.77 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $54.14 / $91.54
| Professional | | $36.74 | $54.14 | $91.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.68 / $34.68 / $36.77
| Facility | | $34.68 | $34.68 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.25 / $31.25 / $36.77
| Professional | | $31.25 | $31.25 | $36.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.46 / $36.77 / $59.60
| Professional | | $33.46 | $36.77 | $59.60 |