- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.46 / $52.46 / $52.46
| Facility | | $52.46 | $52.46 | $52.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $54.08 / $66.01
| Professional | | $51.32 | $54.08 | $66.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.33 / $85.72 / $106.83
| Professional | | $60.33 | $85.72 | $106.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.83 / $63.81 / $121.87
| Facility | | $51.83 | $63.81 | $121.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.59 / $75.81 / $404.24
| Professional | | $58.59 | $75.81 | $404.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.34 / $72.38 / $96.04
| Professional | | $55.34 | $72.38 | $96.04 |