- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.63 / $258.55 / $325.10
| Facility | | $206.63 | $258.55 | $325.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.33 / $225.82 / $362.27
| Professional | | $106.33 | $225.82 | $362.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.63 / $255.99 / $537.05
| Facility | | $206.63 | $255.99 | $537.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.71 / $215.30 / $310.72
| Professional | | $125.71 | $215.30 | $310.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.84 / $197.84 / $197.84
| Facility | | $197.84 | $197.84 | $197.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.00 / $406.32 / $406.32
| Professional | | $95.00 | $406.32 | $406.32 |