- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.78 / $157.78 / $157.78
| Facility | | $157.78 | $157.78 | $157.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.51 / $157.53 / $157.78
| Professional | | $135.51 | $157.53 | $157.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.77 / $239.74 / $245.71
| Professional | | $202.77 | $239.74 | $245.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.88 / $265.50 / $333.85
| Professional | | $262.88 | $265.50 | $333.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.09 / $157.78 / $1,155.77
| Facility | | $103.09 | $157.78 | $1,155.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.40 / $108.19 / $180.32
| Professional | | $86.40 | $108.19 | $180.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.71 / $120.11 / $257.39
| Professional | | $84.71 | $120.11 | $257.39 |