- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $67.61
| Facility | | $56.23 | $56.23 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $56.23 / $61.66
| Professional | | $36.31 | $56.23 | $61.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,047.13 / $1,584.89
| Facility | | $398.11 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.41 / $7.41 / $7.41
| Professional | | $7.41 | $7.41 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.24 / $3.24 / $3.24
| Professional | | $3.24 | $3.24 | $3.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $263.03 / $263.03
| Professional | | $257.04 | $263.03 | $263.03 |