- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.07 / $163.98 / $239.87
| Facility | | $137.07 | $163.98 | $239.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.59 / $151.15 / $180.67
| Professional | | $131.59 | $151.15 | $180.67 |
- 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
- $165.84 / $194.03 / $365.02
| Professional | | $165.84 | $194.03 | $365.02 |