- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $512.86 / $512.86
| Facility | | $56.23 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $56.23 / $524.81
| Professional | | $38.02 | $56.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $257.04 / $346.74
| Professional | | $204.17 | $257.04 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $263.03 / $524.81
| Professional | | $117.49 | $263.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $446.68
| Professional | | $288.40 | $354.81 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $50.12 / $79.43
| Professional | | $38.02 | $50.12 | $79.43 |