- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.12 / $145.12 / $373.16
| Facility | | $145.12 | $145.12 | $373.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.12 / $194.87 / $194.87
| Professional | | $145.12 | $194.87 | $194.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.06 / $417.73 / $466.45
| Professional | | $312.06 | $417.73 | $466.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.30 / $238.30 / $349.84
| Professional | | $238.30 | $238.30 | $349.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.39 / $157.56 / $373.16
| Facility | | $124.39 | $157.56 | $373.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $248.77 / $414.62
| Professional | | $105.73 | $248.77 | $414.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $211.46 / $352.43
| Professional | | $87.07 | $211.46 | $352.43 |