- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $44.67 / $1,348.96
| Professional | | $30.20 | $44.67 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $831.76
| Professional | | $398.11 | $616.60 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $54.95 / $87.10
| Professional | | $50.12 | $54.95 | $87.10 |