- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.20 / $55.74 / $306.31
| Facility | | $43.20 | $55.74 | $306.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.64 / $47.64 / $52.40
| Professional | | $47.64 | $47.64 | $52.40 |
- 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
- $50.10 / $50.10 / $50.10
| Professional | | $50.10 | $50.10 | $50.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.85 / $107.06 / $191.33
| Facility | | $50.85 | $107.06 | $191.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.73 / $50.54 / $53.53
| Professional | | $44.73 | $50.54 | $53.53 |