- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $223.87 / $316.23
| Facility | | $204.17 | $223.87 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $457.09
| Professional | | $316.23 | $316.23 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $35.48 / $69.18
| Facility | | $33.88 | $35.48 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.45 / $2.45 / $3.09
| Professional | | $2.45 | $2.45 | $3.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $316.23 / $436.52
| Facility | | $251.19 | $316.23 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $77.62 / $134.90
| Facility | | $22.91 | $77.62 | $134.90 |