- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.39 / $230.39 / $421.74
| Facility | | $230.39 | $230.39 | $421.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.73 / $83.73 / $146.55
| Professional | | $83.73 | $83.73 | $146.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.61 / $140.72 / $140.72
| Professional | | $57.61 | $140.72 | $140.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.91 / $335.91 / $335.91
| Facility | | $335.91 | $335.91 | $335.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.20 / $260.00 / $470.69
| Professional | | $108.20 | $260.00 | $470.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.68 / $140.72 / $286.77
| Professional | | $15.68 | $140.72 | $286.77 |