- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.02 / $218.02 / $301.07
| Facility | | $218.02 | $218.02 | $301.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.82 / $218.02 / $218.02
| Professional | | $103.82 | $218.02 | $218.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.47 / $130.47 / $258.68
| Facility | | $112.47 | $130.47 | $258.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.07 / $205.39 / $248.83
| Professional | | $199.07 | $205.39 | $248.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.72 / $155.72 / $155.72
| Facility | | $155.72 | $155.72 | $155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.67 / $103.82 / $173.03
| Professional | | $72.67 | $103.82 | $173.03 |