- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.18 / $195.18 / $400.92
| Facility | | $195.18 | $195.18 | $400.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $195.18 / $195.18
| Professional | | $110.00 | $195.18 | $195.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.22 / $192.15 / $471.70
| Facility | | $132.22 | $192.15 | $471.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.94 / $148.68 / $182.00
| Professional | | $118.94 | $148.68 | $182.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.41 / $373.41 / $373.41
| Facility | | $373.41 | $373.41 | $373.41 |