- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.57 / $106.57 / $186.48
| Facility | | $106.57 | $106.57 | $186.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.04 / $106.57 / $596.60
| Professional | | $91.04 | $106.57 | $596.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.02 / $226.23 / $266.92
| Professional | | $211.02 | $226.23 | $266.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.15 / $186.21 / $252.39
| Professional | | $129.15 | $186.21 | $252.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.09 / $148.44 / $266.31
| Facility | | $104.09 | $148.44 | $266.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.99 / $196.16 / $664.64
| Professional | | $108.99 | $196.16 | $664.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.99 / $191.53 / $265.67
| Professional | | $108.99 | $191.53 | $265.67 |