- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.26 / $53.26 / $53.26
| Facility | | $53.26 | $53.26 | $53.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.58 / $38.44 / $38.44
| Professional | | $36.58 | $38.44 | $38.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.10 / $30.10 / $30.10
| Facility | | $30.10 | $30.10 | $30.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.33 / $53.28 / $66.59
| Professional | | $24.33 | $53.28 | $66.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.31 / $123.18 / $309.70
| Facility | | $46.31 | $123.18 | $309.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.82 / $22.77 / $47.43
| Professional | | $16.82 | $22.77 | $47.43 |