- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $758.58
| Facility | | $34.67 | $34.67 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $1,096.48
| Professional | | $34.67 | $50.12 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $602.56 / $933.25
| Professional | | $407.38 | $602.56 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $79.43 / $138.04
| Professional | | $48.98 | $79.43 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $69.18 / $104.71
| Professional | | $39.81 | $69.18 | $104.71 |