- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.77 / $31.77 / $31.77
| Facility | | $31.77 | $31.77 | $31.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.37 / $31.77 / $43.31
| Professional | | $28.37 | $31.77 | $43.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.66 / $1,335.89 / $1,552.11
| Facility | | $1,334.66 | $1,335.89 | $1,552.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.21 / $176.84 / $176.84
| Professional | | $148.21 | $176.84 | $176.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.08 / $53.69 / $74.81
| Facility | | $35.08 | $53.69 | $74.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.64 / $221.34 / $221.34
| Professional | | $44.64 | $221.34 | $221.34 |