- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.64 / $228.09 / $253.02
| Facility | | $124.64 | $228.09 | $253.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.47 / $228.09 / $253.02
| Professional | | $98.47 | $228.09 | $253.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.72 / $153.72 / $153.72
| Facility | | $153.72 | $153.72 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.72 / $153.72 / $153.72
| Professional | | $153.72 | $153.72 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.72 / $104.78 / $213.16
| Professional | | $35.72 | $104.78 | $213.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.04 / $56.09 / $186.96
| Professional | | $34.04 | $56.09 | $186.96 |