- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.24 / $358.24 / $358.24
| Facility | | $358.24 | $358.24 | $358.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.52 / $135.50 / $167.05
| Professional | | $130.52 | $135.50 | $167.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.21 / $200.61 / $332.42
| Professional | | $146.21 | $200.61 | $332.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.44 / $237.15 / $426.51
| Professional | | $143.44 | $237.15 | $426.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.38 / $329.86 / $595.52
| Professional | | $167.38 | $329.86 | $595.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.29 / $235.83 / $587.45
| Professional | | $146.29 | $235.83 | $587.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.58 / $129.34 / $164.61
| Professional | | $117.58 | $129.34 | $164.61 |