- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.86 / $56.23 / $109.27
| Facility | | $39.86 | $56.23 | $109.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.86 / $39.86 / $40.27
| Professional | | $39.86 | $39.86 | $40.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.61 / $42.25 / $54.68
| Facility | | $37.61 | $42.25 | $54.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.86 / $39.86 / $39.86
| Professional | | $39.86 | $39.86 | $39.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.42 / $86.42 / $13,785.00
| Facility | | $66.42 | $86.42 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.68 / $38.68 / $38.85
| Professional | | $38.68 | $38.68 | $38.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.86 / $39.86 / $46.07
| Professional | | $39.86 | $39.86 | $46.07 |