- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.65 / $153.79 / $244.94
| Facility | | $84.65 | $153.79 | $244.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.96 / $136.96 / $136.96
| Facility | | $136.96 | $136.96 | $136.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.79 / $84.63 / $117.60
| Professional | | $22.79 | $84.63 | $117.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.00 / $21.00 / $86.84
| Facility | | $21.00 | $21.00 | $86.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |