- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $295.48 / $531.86
| Facility | | $246.23 | $295.48 | $531.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $246.23
| Professional | | $246.23 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.68 / $154.68 / $154.68
| Professional | | $154.68 | $154.68 | $154.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.58 / $143.86 / $451.85
| Facility | | $61.58 | $143.86 | $451.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.47 / $246.23 / $283.16
| Facility | | $122.47 | $246.23 | $283.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.00 / $266.00 / $306.64
| Professional | | $266.00 | $266.00 | $306.64 |