- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $208.93 / $416.87
| Facility | | $109.65 | $208.93 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $97.72 / $120.23
| Professional | | $77.62 | $97.72 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $204.17 / $257.04
| Facility | | $102.33 | $204.17 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $162.18
| Professional | | $128.82 | $128.82 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $91.20 / $194.98
| Facility | | $58.88 | $91.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $67.61 / $112.20
| Professional | | $46.77 | $67.61 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.77 / $112.20 / $134.90
| Facility | | $46.77 | $112.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $67.61 / $112.20
| Professional | | $46.77 | $67.61 | $112.20 |