- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.03 / $203.56 / $445.56
| Facility | | $75.03 | $203.56 | $445.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $124.59 / $156.37
| Professional | | $123.36 | $124.59 | $156.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.52 / $147.52 / $147.52
| Facility | | $147.52 | $147.52 | $147.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.52 / $147.52 / $148.66
| Professional | | $147.52 | $147.52 | $148.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.38 / $123.36 / $123.36
| Facility | | $116.38 | $123.36 | $123.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.36 / $123.36 / $123.36
| Professional | | $123.36 | $123.36 | $123.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.44 / $123.36 / $123.36
| Professional | | $118.44 | $123.36 | $123.36 |