- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.36 / $211.34 / $552.86
| Facility | | $185.36 | $211.34 | $552.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.34 / $211.34 / $211.34
| Professional | | $211.34 | $211.34 | $211.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.32 / $188.70 / $188.70
| Professional | | $128.32 | $188.70 | $188.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.82 / $156.38 / $344.57
| Facility | | $89.82 | $156.38 | $344.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.79 / $156.11 / $195.14
| Professional | | $80.79 | $156.11 | $195.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.34 / $81.52 / $123.16
| Professional | | $54.34 | $81.52 | $123.16 |