- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | 50 | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $331.13 / $338.84
| Facility | | $123.03 | $331.13 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $302.00
| Professional | | $169.82 | $208.93 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.51 / $40.74 / $114.82
| Facility | | $29.51 | $40.74 | $114.82 |