- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.77 / $186.76 / $305.85
| Facility | | $174.77 | $186.76 | $305.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.52 / $168.94 / $191.25
| Professional | | $126.52 | $168.94 | $191.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.38 / $788.47 / $788.47
| Facility | | $280.38 | $788.47 | $788.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.55 / $1,105.55 / $1,277.03
| Professional | | $1,105.55 | $1,105.55 | $1,277.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.30 / $187.67 / $363.10
| Professional | | $165.30 | $187.67 | $363.10 |