- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.46 / $314.46 / $314.46
| Facility | | $314.46 | $314.46 | $314.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.27 / $356.15 / $599.79
| Professional | | $42.27 | $356.15 | $599.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.43 / $63.76 / $75.02
| Professional | | $39.43 | $63.76 | $75.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.86 / $366.86 / $366.86
| Facility | | $366.86 | $366.86 | $366.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $118.57 / $420.70
| Professional | | $102.26 | $118.57 | $420.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.58 / $53.60 / $106.48
| Professional | | $41.58 | $53.60 | $106.48 |