- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $154.88 / $371.54
| Facility | | $109.65 | $154.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $51.29 / $58.88
| Professional | | $46.77 | $51.29 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $147.91 / $295.12
| Facility | | $120.23 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $46.77 / $64.57
| Professional | | $46.77 | $46.77 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |