- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.55 / $160.75 / $214.33
| Facility | | $107.55 | $160.75 | $214.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.19 / $154.47 / $396.94
| Professional | | $118.19 | $154.47 | $396.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.86 / $331.98 / $426.73
| Professional | | $253.86 | $331.98 | $426.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.36 / $218.37 / $272.95
| Professional | | $148.36 | $218.37 | $272.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.00 / $172.00 / $266.98
| Facility | | $140.00 | $172.00 | $266.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.18 / $210.14 / $1,103.45
| Professional | | $147.18 | $210.14 | $1,103.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.44 / $178.62 / $260.56
| Professional | | $145.44 | $178.62 | $260.56 |