- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.40 / $44.75 / $65.47
| Facility | | $37.40 | $44.75 | $65.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.40 / $44.75 / $51.03
| Professional | | $37.40 | $44.75 | $51.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.28 / $64.28 / $64.28
| Professional | | $64.28 | $64.28 | $64.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Facility | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.02 / $391.64 / $596.54
| Professional | | $272.02 | $391.64 | $596.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.87 / $51.61 / $95.32
| Professional | | $43.87 | $51.61 | $95.32 |