- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.47 / $162.37 / $197.75
| Facility | | $52.47 | $162.37 | $197.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $53.00
| Professional | | $52.47 | $52.47 | $53.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.04 / $52.04 / $62.34
| Professional | | $52.04 | $52.04 | $62.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.50 / $49.50 / $52.47
| Facility | | $49.50 | $49.50 | $52.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $52.47 / $65.87
| Professional | | $52.47 | $52.47 | $65.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.60 / $48.58 / $54.66
| Professional | | $44.60 | $48.58 | $54.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.47 / $58.41 / $77.23
| Professional | | $52.47 | $58.41 | $77.23 |