- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $102.33
| Facility | | $57.54 | $57.54 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.48 / $35.48 / $35.48
| Professional | | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $5.01 / $5.01
| Professional | | $5.01 | $5.01 | $5.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $89.13 / $102.33
| Facility | | $57.54 | $89.13 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $79.43 / $79.43
| Professional | | $60.26 | $79.43 | $79.43 |