- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.86 / $53.86 / $57.60
| Facility | | $53.86 | $53.86 | $57.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.08 / $53.47 / $68.52
| Professional | | $46.08 | $53.47 | $68.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.58 / $59.58 / $59.58
| Facility | | $59.58 | $59.58 | $59.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.15 / $87.71 / $114.42
| Professional | | $67.15 | $87.71 | $114.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.31 / $73.31 / $73.31
| Professional | | $73.31 | $73.31 | $73.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.50 / $102.50 / $144.50
| Professional | | $77.50 | $102.50 | $144.50 |