- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $51.29 / $54.95
| Facility | | $34.67 | $51.29 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $79.43
| Professional | | $34.67 | $44.67 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $3,715.35
| Facility | | $1,905.46 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $64.57 / $223.87
| Professional | | $50.12 | $64.57 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $60.26 / $89.13
| Professional | | $44.67 | $60.26 | $89.13 |