- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.35 / $99.35 / $165.29
| Facility | | $99.35 | $99.35 | $165.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.50 / $99.35 / $165.29
| Professional | | $85.50 | $99.35 | $165.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.80 / $216.79 / $256.41
| Professional | | $198.80 | $216.79 | $256.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $224.64 / $290.08
| Professional | | $124.57 | $224.64 | $290.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.35 / $168.90 / $2,478.69
| Facility | | $99.35 | $168.90 | $2,478.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.53 / $188.68 / $254.10
| Professional | | $110.53 | $188.68 | $254.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.53 / $200.96 / $254.10
| Professional | | $110.53 | $200.96 | $254.10 |