- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.21 / $157.21 / $264.63
| Facility | | $157.21 | $157.21 | $264.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.94 / $172.89 / $264.63
| Professional | | $148.94 | $172.89 | $264.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $132.00 / $132.00
| Professional | | $132.00 | $132.00 | $132.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.44 / $293.89 / $382.44
| Facility | | $133.44 | $293.89 | $382.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.06 / $146.68 / $207.30
| Professional | | $104.06 | $146.68 | $207.30 |
- 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
- $102.49 / $131.87 / $204.29
| Professional | | $102.49 | $131.87 | $204.29 |