- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.44 / $150.44 / $152.88
| Facility | | $150.44 | $150.44 | $152.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.87 / $147.18 / $152.88
| Professional | | $130.87 | $147.18 | $152.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.78 / $193.05 / $481.97
| Professional | | $163.78 | $193.05 | $481.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.75 / $183.51 / $306.02
| Professional | | $104.75 | $183.51 | $306.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.68 / $187.26 / $306.02
| Professional | | $155.68 | $187.26 | $306.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.21 / $204.91 / $558.76
| Professional | | $192.21 | $204.91 | $558.76 |