- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.23 / $159.07 / $293.56
| Facility | | $114.23 | $159.07 | $293.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.24 / $264.64 / $293.56
| Professional | | $114.24 | $264.64 | $293.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.15 / $231.15 / $231.15
| Facility | | $231.15 | $231.15 | $231.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.15 / $231.15 / $231.15
| Professional | | $231.15 | $231.15 | $231.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.00 / $138.16 / $253.66
| Facility | | $94.00 | $138.16 | $253.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.68 / $161.04 / $292.58
| Professional | | $62.68 | $161.04 | $292.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.77 / $144.61 / $361.53
| Professional | | $86.77 | $144.61 | $361.53 |