- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.60 / $286.24 / $304.67
| Facility | | $151.60 | $286.24 | $304.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.15 / $96.15 / $304.67
| Professional | | $75.15 | $96.15 | $304.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.76 / $104.76 / $104.76
| Facility | | $104.76 | $104.76 | $104.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.76 / $104.76 / $104.76
| Professional | | $104.76 | $104.76 | $104.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $354.55 / $430.17
| Professional | | $138.94 | $354.55 | $430.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $45.00 / $80.00
| Professional | | $25.00 | $45.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.81 / $85.34 / $208.06
| Professional | | $63.81 | $85.34 | $208.06 |