- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $467.74
| Professional | | $34.67 | $44.67 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $426.58 / $489.78
| Professional | | $275.42 | $426.58 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $83.18 / $100.00
| Professional | | $50.12 | $83.18 | $100.00 |