- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.31 / $329.31 / $329.31
| Facility | | $329.31 | $329.31 | $329.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $121.03 / $199.36
| Professional | | $108.36 | $121.03 | $199.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $97.10 / $108.36
| Professional | | $3.50 | $97.10 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.73 / $195.76 / $301.13
| Professional | | $68.73 | $195.76 | $301.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.54 / $267.94 / $517.88
| Professional | | $143.54 | $267.94 | $517.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.39 / $206.87 / $211.10
| Professional | | $191.39 | $206.87 | $211.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.44 / $146.36 / $250.64
| Professional | | $84.44 | $146.36 | $250.64 |