- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Facility | | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $52.48 / $72.44
| Professional | | $42.66 | $52.48 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.62 / $302.00 / $7,585.78
| Facility | | $31.62 | $302.00 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $218.78 / $218.78
| Professional | | $177.83 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $64.57 / $104.71
| Facility | | $47.86 | $64.57 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |