- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.79 / $287.79 / $287.79
| Facility | | $287.79 | $287.79 | $287.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.03 / $128.13 / $236.47
| Professional | | $92.03 | $128.13 | $236.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.13 / $128.13 / $128.13
| Professional | | $128.13 | $128.13 | $128.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.09 / $123.82 / $273.20
| Professional | | $53.09 | $123.82 | $273.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.13 / $112.78 / $232.98
| Professional | | $37.13 | $112.78 | $232.98 |