- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.67 / $144.61 / $676.60
| Facility | | $57.67 | $144.61 | $676.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.67 / $57.67 / $61.81
| Professional | | $57.67 | $57.67 | $61.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.71 / $63.71 / $63.71
| Professional | | $63.71 | $63.71 | $63.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.75 / $72.03 / $195.32
| Professional | | $56.75 | $72.03 | $195.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.25 / $130.36 / $130.36
| Professional | | $58.25 | $130.36 | $130.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.37 / $130.99 / $165.08
| Professional | | $47.37 | $130.99 | $165.08 |