- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.75 / $202.75 / $281.14
| Facility | | $202.75 | $202.75 | $281.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $109.10 / $204.40
| Professional | | $93.39 | $109.10 | $204.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.10 / $173.59 / $207.66
| Professional | | $134.10 | $173.59 | $207.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.77 / $204.40 / $255.61
| Facility | | $131.77 | $204.40 | $255.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.07 / $212.20 / $259.76
| Professional | | $175.07 | $212.20 | $259.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $195.80
| Professional | | $32.34 | $32.34 | $195.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.84 / $221.26 / $259.76
| Professional | | $203.84 | $221.26 | $259.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.42 / $139.40 / $229.22
| Professional | | $117.42 | $139.40 | $229.22 |