- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.40 / $336.83 / $810.29
| Facility | | $237.40 | $336.83 | $810.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.81 / $116.33 / $134.30
| Professional | | $106.81 | $116.33 | $134.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.02 / $296.97 / $638.03
| Facility | | $187.02 | $296.97 | $638.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.75 / $105.75 / $105.75
| Professional | | $105.75 | $105.75 | $105.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.56 / $137.56 / $137.56
| Facility | | $137.56 | $137.56 | $137.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.70 / $283.70 / $283.70
| Professional | | $283.70 | $283.70 | $283.70 |