- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.22 / $210.61 / $323.08
| Facility | | $180.22 | $210.61 | $323.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.24 / $193.20 / $228.72
| Professional | | $127.24 | $193.20 | $228.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.79 / $335.79 / $335.79
| Professional | | $335.79 | $335.79 | $335.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.66 / $145.66 / $145.66
| Facility | | $145.66 | $145.66 | $145.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.96 / $335.79 / $335.79
| Professional | | $121.96 | $335.79 | $335.79 |