- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.30 / $430.30 / $537.80
| Facility | | $430.30 | $430.30 | $537.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.05 / $102.75 / $203.86
| Professional | | $89.05 | $102.75 | $203.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.60 / $109.60 / $124.94
| Professional | | $109.60 | $109.60 | $124.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.91 / $84.75 / $336.41
| Professional | | $70.91 | $84.75 | $336.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.00 / $164.40 / $205.50
| Professional | | $137.00 | $164.40 | $205.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $63.02 / $124.67
| Professional | | $57.54 | $63.02 | $124.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.50 / $108.92 / $108.92
| Professional | | $68.50 | $108.92 | $108.92 |