- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.77 / $37.77 / $37.77
| Facility | | $37.77 | $37.77 | $37.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.77 / $53.96 / $287.63
| Professional | | $37.77 | $53.96 | $287.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.91 / $43.91 / $118.50
| Professional | | $43.91 | $43.91 | $118.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.45 / $100.88 / $100.88
| Facility | | $90.45 | $100.88 | $100.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.44 / $72.31 / $108.47
| Professional | | $57.44 | $72.31 | $108.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.72 / $45.64 / $54.89
| Professional | | $35.72 | $45.64 | $54.89 |