- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.07 / $71.65 / $1,035.52
| Facility | | $53.07 | $71.65 | $1,035.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $55.73
| Professional | | $53.08 | $53.08 | $55.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.70 / $603.98 / $812.55
| Facility | | $497.70 | $603.98 | $812.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.56 / $46.56 / $46.56
| Professional | | $46.56 | $46.56 | $46.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.49 / $47.49 / $47.49
| Facility | | $47.49 | $47.49 | $47.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.49 / $47.49 / $101.68
| Professional | | $47.49 | $47.49 | $101.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.08 / $53.08 / $53.08
| Professional | | $53.08 | $53.08 | $53.08 |