- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.08 / $290.63 / $290.63
| Facility | | $159.08 | $290.63 | $290.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.08 / $196.00 / $281.42
| Professional | | $159.08 | $196.00 | $281.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.00 / $241.00 / $241.00
| Professional | | $241.00 | $241.00 | $241.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.79 / $495.79 / $495.79
| Facility | | $495.79 | $495.79 | $495.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.78 / $212.09 / $281.95
| Professional | | $158.78 | $212.09 | $281.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.25 / $184.06 / $245.61
| Professional | | $146.25 | $184.06 | $245.61 |