- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $275.42
| Facility | | $218.78 | $218.78 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $275.42 / $275.42
| Professional | | $104.71 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $162.18
| Facility | | $100.00 | $120.23 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $173.78
| Professional | | $134.90 | $134.90 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $131.83 / $524.81
| Facility | | $39.81 | $131.83 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.38 / $257.04 / $281.84
| Facility | | $21.38 | $257.04 | $281.84 |