- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.14 / $304.14 / $304.14
| Facility | | $304.14 | $304.14 | $304.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.52 / $131.85 / $235.57
| Professional | | $107.52 | $131.85 | $235.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.34 / $189.71 / $303.76
| Professional | | $109.34 | $189.71 | $303.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.79 / $410.52 / $410.52
| Facility | | $199.79 | $410.52 | $410.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $170.63 / $352.51
| Professional | | $121.56 | $170.63 | $352.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.46 / $177.35 / $248.23
| Professional | | $138.46 | $177.35 | $248.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.28 / $160.59 / $314.19
| Professional | | $114.28 | $160.59 | $314.19 |