- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.93 / $773.93 / $773.93
| Facility | | $773.93 | $773.93 | $773.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.48 / $21.77 / $30.58
| Professional | | $17.48 | $21.77 | $30.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.05 / $28.62 / $39.61
| Professional | | $23.05 | $28.62 | $39.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.69 / $38.71 / $58.07
| Professional | | $27.69 | $38.71 | $58.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.14 / $32.15 / $50.03
| Professional | | $25.14 | $32.15 | $50.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.48 / $21.77 / $41.30
| Professional | | $17.48 | $21.77 | $41.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.08 / $37.96 / $52.73
| Professional | | $30.08 | $37.96 | $52.73 |