- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.46 / $238.58 / $414.92
| Facility | | $207.46 | $238.58 | $414.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $238.58 / $238.58
| Professional | | $161.82 | $238.58 | $238.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.15 / $191.92 / $258.19
| Facility | | $158.15 | $191.92 | $258.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.22 / $144.22 / $144.22
| Professional | | $144.22 | $144.22 | $144.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.61 / $178.77 / $651.05
| Facility | | $152.61 | $178.77 | $651.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.70 / $159.51 / $1,156.92
| Professional | | $91.70 | $159.51 | $1,156.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.13 / $118.87 / $207.46
| Professional | | $87.13 | $118.87 | $207.46 |