- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $489.78
| Facility | | $371.54 | $371.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $50.12 / $741.31
| Professional | | $30.20 | $50.12 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.80 / $6.61
| Professional | | $3.02 | $3.80 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $371.54 / $794.33
| Professional | | $269.15 | $371.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $371.54 / $489.78
| Professional | | $269.15 | $371.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $60.26 / $87.10
| Professional | | $44.67 | $60.26 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |