- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.37 / $136.35 / $829.01
| Facility | | $122.37 | $136.35 | $829.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.35 / $136.35 / $139.85
| Professional | | $136.35 | $136.35 | $139.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.81 / $183.55 / $241.24
| Professional | | $174.81 | $183.55 | $241.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.49 / $354.53 / $996.76
| Facility | | $116.49 | $354.53 | $996.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.35 / $174.81 / $211.52
| Facility | | $136.35 | $174.81 | $211.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $104.89 / $159.18
| Professional | | $73.42 | $104.89 | $159.18 |