- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.94 / $153.94 / $192.43
| Facility | | $153.94 | $153.94 | $192.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.69 / $192.43 / $203.05
| Professional | | $134.69 | $192.43 | $203.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.78 / $327.33 / $1,272.19
| Professional | | $171.78 | $327.33 | $1,272.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.13 / $4,042.45 / $4,042.45
| Facility | | $352.13 | $4,042.45 | $4,042.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.32 / $1,308.32 / $1,460.10
| Professional | | $1,308.32 | $1,308.32 | $1,460.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.95 / $239.94 / $450.74
| Professional | | $199.95 | $239.94 | $450.74 |