- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $331.13 / $407.38
| Facility | | $288.40 | $331.13 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $186.21 / $371.54
| Facility | | $107.15 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $147.91 / $467.74
| Professional | | $100.00 | $147.91 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Facility | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |