- 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
- $32.36 / $436.52 / $1,202.26
| Professional | | $32.36 | $436.52 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $281.84
| Professional | | $251.19 | $251.19 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $245.47 / $331.13
| Professional | | $158.49 | $245.47 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $54.95 / $87.10
| Professional | | $50.12 | $54.95 | $87.10 |