- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.31 / $337.12 / $517.75
| Facility | | $204.31 | $337.12 | $517.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $126.35 / $519.65
| Professional | | $38.00 | $126.35 | $519.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.44 / $360.25 / $631.67
| Facility | | $237.44 | $360.25 | $631.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.76 / $120.76 / $120.76
| Professional | | $120.76 | $120.76 | $120.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.05 / $228.24 / $502.20
| Facility | | $58.05 | $228.24 | $502.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.20 / $126.35 / $252.03
| Professional | | $67.20 | $126.35 | $252.03 |