- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $151.36 / $251.19
| Facility | | $75.86 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $251.19 / $363.08
| Professional | | $245.47 | $251.19 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $28.84 / $28.84
| Professional | | $28.84 | $28.84 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Professional | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $42.66 / $50.12
| Professional | | $42.66 | $42.66 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $263.03 / $407.38
| Professional | | $251.19 | $263.03 | $407.38 |