- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.94 / $175.94 / $336.47
| Facility | | $175.94 | $175.94 | $336.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.94 / $219.92 / $219.92
| Professional | | $175.94 | $219.92 | $219.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.56 / $193.09 / $195.86
| Professional | | $163.56 | $193.09 | $195.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.75 / $6.82 / $8.57
| Professional | | $6.75 | $6.82 | $8.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.98 / $175.94 / $527.82
| Facility | | $16.98 | $175.94 | $527.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.26 / $183.26 / $199.03
| Professional | | $183.26 | $183.26 | $199.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.77 / $183.26 / $199.03
| Professional | | $155.77 | $183.26 | $199.03 |