- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.52 / $149.90 / $278.04
| Facility | | $137.52 | $149.90 | $278.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.33 / $87.33 / $108.19
| Professional | | $87.33 | $87.33 | $108.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.73 / $84.73 / $84.73
| Facility | | $84.73 | $84.73 | $84.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.60 / $105.24 / $261.98
| Professional | | $93.60 | $105.24 | $261.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.35 / $130.35 / $130.35
| Facility | | $130.35 | $130.35 | $130.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.75 / $109.27 / $286.77
| Professional | | $54.75 | $109.27 | $286.77 |