- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.39 / $362.42 / $583.07
| Facility | | $195.39 | $362.42 | $583.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.83 / $113.83 / $141.02
| Professional | | $113.83 | $113.83 | $141.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.44 / $110.44 / $110.44
| Facility | | $110.44 | $110.44 | $110.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.70 / $176.70 / $176.70
| Professional | | $176.70 | $176.70 | $176.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.70 / $236.20 / $808.62
| Facility | | $77.70 | $236.20 | $808.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.36 / $254.85 / $373.78
| Professional | | $71.36 | $254.85 | $373.78 |