- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.10 / $109.10 / $187.33
| Facility | | $109.10 | $109.10 | $187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $109.10 / $172.09
| Professional | | $93.39 | $109.10 | $172.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.02 / $226.61 / $267.75
| Professional | | $211.02 | $226.61 | $267.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.41 / $204.27 / $255.51
| Professional | | $128.41 | $204.27 | $255.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.10 / $172.54 / $327.30
| Facility | | $109.10 | $172.54 | $327.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.52 / $218.20 / $1,846.00
| Professional | | $111.52 | $218.20 | $1,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.52 / $211.81 / $271.86
| Professional | | $111.52 | $211.81 | $271.86 |