- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.38 / $50.38 / $447.14
| Facility | | $50.38 | $50.38 | $447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.38 / $50.38 / $51.58
| Professional | | $50.38 | $50.38 | $51.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.23 / $51.23 / $51.23
| Facility | | $51.23 | $51.23 | $51.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $45.00
| Professional | | $30.00 | $30.00 | $45.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.09 / $116.32 / $169.01
| Facility | | $85.09 | $116.32 | $169.01 |