- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.04 / $37.82 / $62.98
| Professional | | $34.04 | $37.82 | $62.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.54 / $38.54 / $38.54
| Facility | | $38.54 | $38.54 | $38.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.11 / $44.77 / $115.10
| Facility | | $32.11 | $44.77 | $115.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.04 / $34.04 / $34.04
| Professional | | $34.04 | $34.04 | $34.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.11 / $44.77 / $115.10
| Facility | | $32.11 | $44.77 | $115.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.04 / $34.04 / $34.04
| Professional | | $34.04 | $34.04 | $34.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.35 / $34.04 / $52.38
| Professional | | $32.35 | $34.04 | $52.38 |