- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.97 / $173.97 / $217.46
| Facility | | $173.97 | $173.97 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Professional | | $217.46 | $217.46 | $217.46 |
- 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
- $135.38 / $135.38 / $173.08
| Professional | | $135.38 | $135.38 | $173.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |