- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.65 / $46.70 / $154.65
| Facility | | $28.65 | $46.70 | $154.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.40 / $36.85 / $44.22
| Professional | | $36.40 | $36.85 | $44.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.23 / $61.19 / $114.40
| Facility | | $44.23 | $61.19 | $114.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $37.74 / $68.13
| Professional | | $37.00 | $37.74 | $68.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.74 / $37.74 / $37.74
| Facility | | $37.74 | $37.74 | $37.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.74 / $37.74 / $37.74
| Professional | | $37.74 | $37.74 | $37.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $37.00 / $51.47
| Professional | | $37.00 | $37.00 | $51.47 |