- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.30 / $150.30 / $637.65
| Facility | | $150.30 | $150.30 | $637.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.18 / $170.31 / $966.43
| Professional | | $90.18 | $170.31 | $966.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.10 / $154.47 / $187.88
| Professional | | $104.10 | $154.47 | $187.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.30 / $150.30 / $150.30
| Facility | | $150.30 | $150.30 | $150.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.61 / $203.69 / $317.20
| Professional | | $89.61 | $203.69 | $317.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.24 / $138.40 / $281.22
| Professional | | $52.24 | $138.40 | $281.22 |