- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.46 / $169.75 / $211.73
| Facility | | $141.46 | $169.75 | $211.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.63 / $180.47 / $302.08
| Professional | | $150.63 | $180.47 | $302.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.52 / $125.55 / $202.76
| Facility | | $86.52 | $125.55 | $202.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.50 / $124.60 / $225.40
| Professional | | $90.50 | $124.60 | $225.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.64 / $348.00 / $348.00
| Facility | | $208.64 | $348.00 | $348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.69 / $405.69 / $405.69
| Professional | | $405.69 | $405.69 | $405.69 |