- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.14 / $201.21 / $221.64
| Facility | | $172.14 | $201.21 | $221.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.07 / $33.63 / $38.60
| Professional | | $31.07 | $33.63 | $38.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.89 / $37.74 / $62.99
| Professional | | $36.89 | $37.74 | $62.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.96 / $194.96 / $194.96
| Facility | | $194.96 | $194.96 | $194.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.46 / $39.88 / $122.36
| Professional | | $34.46 | $39.88 | $122.36 |