- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.27 / $47.27 / $47.27
| Facility | | $47.27 | $47.27 | $47.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.78 / $47.27 / $53.50
| Professional | | $32.78 | $47.27 | $53.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.91 / $97.63 / $114.25
| Professional | | $95.91 | $97.63 | $114.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.36 / $56.30 / $86.01
| Facility | | $45.36 | $56.30 | $86.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.78 / $262.88 / $262.88
| Professional | | $89.78 | $262.88 | $262.88 |