- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.31 / $59.31 / $75.23
| Facility | | $59.31 | $59.31 | $75.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.86 / $52.67 / $75.23
| Professional | | $40.86 | $52.67 | $75.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.25 / $72.45 / $105.74
| Professional | | $50.25 | $72.45 | $105.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.75 / $82.63 / $104.14
| Professional | | $64.75 | $82.63 | $104.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.86 / $53.86 / $53.86
| Professional | | $53.86 | $53.86 | $53.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.86 / $86.56 / $116.69
| Professional | | $59.86 | $86.56 | $116.69 |