- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.98 / $196.98 / $246.23
| Facility | | $196.98 | $196.98 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $246.23
| Professional | | $246.23 | $246.23 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.76 / $73.84 / $87.14
| Professional | | $57.76 | $73.84 | $87.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |