- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.30 / $163.75 / $285.48
| Facility | | $151.30 | $163.75 | $285.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.39 / $151.30 / $163.75
| Professional | | $96.39 | $151.30 | $163.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.21 / $134.75 / $137.43
| Professional | | $108.21 | $134.75 | $137.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.30 / $163.75 / $345.81
| Facility | | $80.30 | $163.75 | $345.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.71 / $149.49 / $327.50
| Professional | | $113.71 | $149.49 | $327.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.71 / $149.49 / $209.83
| Professional | | $113.71 | $149.49 | $209.83 |