- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.23 / $261.14 / $973.08
| Facility | | $53.23 | $261.14 | $973.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $58.38
| Professional | | $53.08 | $53.08 | $58.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.49 / $47.49 / $55.73
| Facility | | $47.49 | $47.49 | $55.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.49 / $47.49 / $47.49
| Professional | | $47.49 | $47.49 | $47.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $53.08
| Facility | | $53.08 | $53.08 | $53.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $53.08
| Professional | | $53.08 | $53.08 | $53.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $55.87
| Professional | | $53.08 | $53.08 | $55.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $53.08
| Professional | | $53.08 | $53.08 | $53.08 |