- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.34 / $170.77 / $462.11
| Facility | | $145.34 | $170.77 | $462.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.73 / $114.73 / $114.73
| Professional | | $114.73 | $114.73 | $114.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.70 / $68.70 / $68.70
| Professional | | $68.70 | $68.70 | $68.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.73 / $117.02 / $153.74
| Facility | | $114.73 | $117.02 | $153.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.12 / $197.12 / $197.12
| Professional | | $197.12 | $197.12 | $197.12 |