- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $1,348.96
| Facility | | $34.67 | $34.67 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $50.12 / $1,995.26
| Professional | | $34.67 | $50.12 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,778.28
| Professional | | $758.58 | $1,122.02 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $77.62 / $138.04
| Professional | | $44.67 | $77.62 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $69.18 / $104.71
| Professional | | $39.81 | $69.18 | $104.71 |