- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $104.80 / $137.40
| Facility | | $20.00 | $104.80 | $137.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $38.86
| Professional | | $10.58 | $10.58 | $38.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.07 / $143.07 / $143.07
| Facility | | $143.07 | $143.07 | $143.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $255.54
| Professional | | $204.44 | $204.44 | $255.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.73 / $323.85 / $471.95
| Facility | | $246.73 | $323.85 | $471.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.30 / $312.75 / $347.50
| Professional | | $236.30 | $312.75 | $347.50 |