- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $724.44
| Facility | | $331.13 | $331.13 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $37.15 / $61.66
| Professional | | $15.85 | $37.15 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $63.10 / $72.44
| Professional | | $63.10 | $63.10 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $39.81 / $74.13
| Professional | | $22.91 | $39.81 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $45.71 / $70.79
| Professional | | $31.62 | $45.71 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $43.65 / $79.43
| Professional | | $26.30 | $43.65 | $79.43 |