- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.35 / $238.54 / $417.88
| Facility | | $130.35 | $238.54 | $417.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.98 / $238.54 / $264.61
| Professional | | $102.98 | $238.54 | $264.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.38 / $190.38 / $190.38
| Facility | | $190.38 | $190.38 | $190.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.38 / $190.38 / $190.38
| Professional | | $190.38 | $190.38 | $190.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.73 / $144.47 / $265.26
| Facility | | $84.73 | $144.47 | $265.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.35 / $138.32 / $305.91
| Professional | | $59.35 | $138.32 | $305.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.75 / $92.31 / $260.70
| Professional | | $54.75 | $92.31 | $260.70 |