- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $169.82 / $229.09
| Facility | | $144.54 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $120.23 / $316.23
| Professional | | $107.15 | $120.23 | $316.23 |
- 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
- $100.00 / $158.49 / $223.87
| Professional | | $100.00 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $158.49 / $288.40
| Professional | | $109.65 | $158.49 | $288.40 |