- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.37 / $236.46 / $365.38
| Facility | | $139.37 | $236.46 | $365.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.82 / $99.55 / $114.43
| Professional | | $85.82 | $99.55 | $114.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.72 / $116.72 / $116.72
| Professional | | $116.72 | $116.72 | $116.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.16 / $187.44 / $259.72
| Facility | | $101.16 | $187.44 | $259.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.54 / $114.43 / $165.29
| Facility | | $91.54 | $114.43 | $165.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $68.66 / $572.15
| Professional | | $48.06 | $68.66 | $572.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $68.66 / $101.19
| Professional | | $48.06 | $68.66 | $101.19 |