- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.50 / $241.50 / $442.09
| Facility | | $241.50 | $241.50 | $442.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.53 / $140.53 / $153.62
| Professional | | $140.53 | $140.53 | $153.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.01 / $147.52 / $147.52
| Professional | | $46.01 | $147.52 | $147.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.11 / $352.11 / $352.11
| Facility | | $352.11 | $352.11 | $352.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.42 / $272.56 / $493.10
| Professional | | $113.42 | $272.56 | $493.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.66 / $147.52 / $300.63
| Professional | | $16.66 | $147.52 | $300.63 |