- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.40 / $320.98 / $356.06
| Facility | | $175.40 | $320.98 | $356.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.57 / $320.98 / $356.06
| Professional | | $138.57 | $320.98 | $356.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.13 / $217.13 / $217.13
| Facility | | $217.13 | $217.13 | $217.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.13 / $217.13 / $217.13
| Professional | | $217.13 | $217.13 | $217.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.01 / $119.71 / $133.05
| Facility | | $114.01 | $119.71 | $133.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $135.81 / $256.22
| Professional | | $75.00 | $135.81 | $256.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.67 / $105.24 / $263.10
| Professional | | $73.67 | $105.24 | $263.10 |