- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.41 / $284.26 / $426.39
| Facility | | $227.41 | $284.26 | $426.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.99 / $284.26 / $284.26
| Professional | | $203.99 | $284.26 | $284.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.66 / $51.66 / $51.66
| Facility | | $51.66 | $51.66 | $51.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.67 / $51.20 / $132.86
| Facility | | $36.67 | $51.20 | $132.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.00 / $254.00 / $317.49
| Professional | | $254.00 | $254.00 | $317.49 |