- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.91 / $70.90 / $667.26
| Facility | | $46.91 | $70.90 | $667.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.53 / $152.97 / $172.10
| Professional | | $104.53 | $152.97 | $172.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.80 / $206.80 / $206.80
| Professional | | $206.80 | $206.80 | $206.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Facility | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.36 / $108.36 / $108.36
| Professional | | $108.36 | $108.36 | $108.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.28 / $218.28 / $242.54
| Professional | | $218.28 | $218.28 | $242.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.99 / $106.24 / $138.11
| Professional | | $101.99 | $106.24 | $138.11 |