- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.33 / $330.33 / $330.33
| Facility | | $330.33 | $330.33 | $330.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.58 / $45.32 / $62.91
| Professional | | $21.58 | $45.32 | $62.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.77 / $71.93 / $109.26
| Professional | | $63.77 | $71.93 | $109.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.55 / $43.51 / $86.27
| Professional | | $25.55 | $43.51 | $86.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.89 / $52.10 / $86.27
| Professional | | $31.89 | $52.10 | $86.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.01 / $67.00 / $127.10
| Professional | | $43.01 | $67.00 | $127.10 |