- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.60 / $265.60 / $280.69
| Facility | | $265.60 | $265.60 | $280.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $121.00 / $1,125.00
| Professional | | $110.00 | $121.00 | $1,125.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.00 / $361.80 / $364.50
| Professional | | $306.00 | $361.80 | $364.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.94 / $120.13 / $151.06
| Professional | | $118.94 | $120.13 | $151.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.60 / $265.60 / $451.52
| Facility | | $265.60 | $265.60 | $451.52 |