- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.38 / $46.28 / $91.54
| Facility | | $42.38 | $46.28 | $91.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.38 / $42.38 / $42.38
| Professional | | $42.38 | $42.38 | $42.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $42.28
| Professional | | $42.28 | $42.28 | $42.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.07 / $1,324.64 / $1,355.28
| Professional | | $1,301.07 | $1,324.64 | $1,355.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.87 / $47.87 / $64.54
| Facility | | $47.87 | $47.87 | $64.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.60 / $42.28 / $49.86
| Professional | | $41.60 | $42.28 | $49.86 |