- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.20 / $193.20 / $193.20
| Facility | | $193.20 | $193.20 | $193.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.52 / $160.52 / $193.20
| Professional | | $160.52 | $160.52 | $193.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.54 / $354.04 / $360.16
| Professional | | $302.54 | $354.04 | $360.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.50 / $310.58 / $390.53
| Professional | | $307.50 | $310.58 | $390.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.94 / $193.20 / $1,325.73
| Facility | | $137.94 | $193.20 | $1,325.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.80 / $149.77 / $224.65
| Professional | | $83.80 | $149.77 | $224.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.77 / $149.77 / $224.65
| Professional | | $71.77 | $149.77 | $224.65 |