- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.17 / $343.17 / $343.17
| Facility | | $343.17 | $343.17 | $343.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.64 / $48.49 / $81.51
| Professional | | $40.64 | $48.49 | $81.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.60 / $43.40 / $53.97
| Professional | | $30.60 | $43.40 | $53.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.20 / $56.79 / $102.04
| Professional | | $43.20 | $56.79 | $102.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.64 / $49.62 / $89.82
| Facility | | $40.64 | $49.62 | $89.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $57.96 / $1,028.34
| Professional | | $48.06 | $57.96 | $1,028.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.36 / $56.61 / $106.54
| Professional | | $47.36 | $56.61 | $106.54 |