- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.29 / $179.29 / $179.29
| Facility | | $179.29 | $179.29 | $179.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.53 / $273.95 / $721.98
| Professional | | $148.53 | $273.95 | $721.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.87 / $218.12 / $313.61
| Professional | | $200.87 | $218.12 | $313.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.07 / $141.04 / $188.87
| Professional | | $117.07 | $141.04 | $188.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.36 / $315.68 / $349.37
| Professional | | $248.36 | $315.68 | $349.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.31 / $217.89 / $287.61
| Professional | | $174.31 | $217.89 | $287.61 |