- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.34 / $352.36 / $847.65
| Facility | | $248.34 | $352.36 | $847.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.07 / $204.61 / $405.93
| Professional | | $108.07 | $204.61 | $405.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.64 / $310.66 / $667.44
| Facility | | $195.64 | $310.66 | $667.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.85 / $189.07 / $343.79
| Professional | | $101.85 | $189.07 | $343.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.86 / $109.85 / $211.68
| Facility | | $46.86 | $109.85 | $211.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.00 / $1,397.77 / $1,397.77
| Professional | | $816.00 | $1,397.77 | $1,397.77 |