- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.54 / $256.80 / $617.78
| Facility | | $164.54 | $256.80 | $617.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $138.57 / $237.88
| Professional | | $110.20 | $138.57 | $237.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.05 / $226.42 / $486.44
| Facility | | $132.05 | $226.42 | $486.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.11 / $129.15 / $220.27
| Professional | | $109.11 | $129.15 | $220.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.56 / $128.34 / $170.40
| Facility | | $93.56 | $128.34 | $170.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.00 / $426.00 / $426.00
| Professional | | $426.00 | $426.00 | $426.00 |