- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.02 / $198.02 / $509.18
| Facility | | $198.02 | $198.02 | $509.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $265.91 / $265.91
| Professional | | $198.02 | $265.91 | $265.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.44 / $325.44 / $477.77
| Professional | | $325.44 | $325.44 | $477.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.66 / $203.67 / $509.18
| Facility | | $99.66 | $203.67 | $509.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $339.46 / $565.76
| Professional | | $144.27 | $339.46 | $565.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $288.54 / $480.90
| Professional | | $118.81 | $288.54 | $480.90 |