- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $478.63
| Facility | | $39.81 | $57.54 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $524.81
| Professional | | $34.67 | $44.67 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $478.63
| Professional | | $281.84 | $338.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |