- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $645.65 / $691.83
| Facility | | $50.12 | $645.65 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $707.95
| Professional | | $30.20 | $44.67 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.66 / $61.66 / $61.66
| Facility | | $61.66 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $524.81 / $1,071.52
| Professional | | $295.12 | $524.81 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $52.48 / $70.79
| Professional | | $44.67 | $52.48 | $70.79 |