- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $181.97
| Facility | | $151.36 | $151.36 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $151.36 / $245.47
| Professional | | $131.83 | $151.36 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $154.88 / $234.42
| Facility | | $112.20 | $154.88 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $275.42
| Professional | | $151.36 | $151.36 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.98 / $91.20 / $112.20
| Facility | | $48.98 | $91.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $21.38 / $40.74
| Professional | | $21.38 | $21.38 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |