- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.14 / $236.68 / $375.70
| Facility | | $53.14 | $236.68 | $375.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.14 / $55.08 / $77.76
| Professional | | $53.14 | $55.08 | $77.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.39 / $55.08 / $55.08
| Facility | | $20.39 | $55.08 | $55.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.08 / $55.08 / $55.08
| Professional | | $55.08 | $55.08 | $55.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.84 / $54.00 / $69.12
| Professional | | $51.84 | $54.00 | $69.12 |