- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.44 / $128.44 / $215.50
| Facility | | $128.44 | $128.44 | $215.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.46 / $128.44 / $129.13
| Professional | | $101.46 | $128.44 | $129.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.97 / $288.54 / $316.33
| Professional | | $239.97 | $288.54 | $316.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.90 / $238.53 / $410.01
| Professional | | $170.90 | $238.53 | $410.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.44 / $180.02 / $428.82
| Facility | | $128.44 | $180.02 | $428.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.97 / $323.06 / $1,787.68
| Professional | | $191.97 | $323.06 | $1,787.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.60 / $273.47 / $349.04
| Professional | | $148.60 | $273.47 | $349.04 |