- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.37 / $122.37 / $314.66
| Facility | | $122.37 | $122.37 | $314.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.37 / $164.32 / $164.32
| Professional | | $122.37 | $164.32 | $164.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.14 / $352.24 / $393.32
| Professional | | $263.14 | $352.24 | $393.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.72 / $200.72 / $294.66
| Professional | | $200.72 | $200.72 | $294.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.89 / $132.86 / $314.66
| Facility | | $104.89 | $132.86 | $314.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.15 / $209.77 / $349.62
| Professional | | $89.15 | $209.77 | $349.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $207.60 / $253.47
| Professional | | $73.42 | $207.60 | $253.47 |