- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $691.83
| Facility | | $204.17 | $295.12 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $151.36 / $245.47
| Professional | | $120.23 | $151.36 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $281.84 / $549.54
| Facility | | $223.87 | $281.84 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $186.21
| Professional | | $117.49 | $117.49 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $128.82 / $204.17
| Facility | | $93.33 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |