- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.36 / $243.36 / $243.36
| Facility | | $243.36 | $243.36 | $243.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.30 / $246.85 / $349.75
| Professional | | $232.30 | $246.85 | $349.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.06 / $48.79 / $67.59
| Facility | | $45.06 | $48.79 | $67.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.68 / $48.79 / $74.20
| Professional | | $46.68 | $48.79 | $74.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.33 / $61.57 / $102.05
| Professional | | $39.33 | $61.57 | $102.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.81 / $24.46 / $76.20
| Professional | | $15.81 | $24.46 | $76.20 |