- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.97 / $197.08 / $474.11
| Facility | | $138.97 | $197.08 | $474.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.57 / $106.35 / $175.80
| Professional | | $84.57 | $106.35 | $175.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.43 / $180.18 / $373.31
| Facility | | $109.43 | $180.18 | $373.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.74 / $83.74 / $153.83
| Professional | | $83.74 | $83.74 | $153.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.22 / $155.55 / $175.95
| Facility | | $100.22 | $155.55 | $175.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.00 / $603.00 / $603.00
| Professional | | $603.00 | $603.00 | $603.00 |