- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.64 / $106.28 / $270.41
| Facility | | $47.64 | $106.28 | $270.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.64 / $47.64 / $47.64
| Professional | | $47.64 | $47.64 | $47.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.50 / $45.50 / $45.50
| Professional | | $45.50 | $45.50 | $45.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.10 / $50.10 / $50.10
| Facility | | $50.10 | $50.10 | $50.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.91 / $57.91 / $57.91
| Professional | | $57.91 | $57.91 | $57.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.28 / $53.53 / $64.23
| Professional | | $44.28 | $53.53 | $64.23 |