- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $630.96 / $660.69
| Facility | | $30.20 | $630.96 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $107.15 / $645.65
| Professional | | $30.20 | $107.15 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $208.93 / $245.47
| Professional | | $186.21 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $436.52 / $602.56
| Professional | | $275.42 | $436.52 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $380.19
| Professional | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |