- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $316.23 / $331.13
| Facility | | $30.20 | $316.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $147.91 / $338.84
| Professional | | $30.20 | $147.91 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $123.03 / $144.54
| Professional | | $109.65 | $123.03 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $173.78 / $223.87
| Professional | | $109.65 | $173.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |