- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.78 / $237.78 / $279.83
| Facility | | $237.78 | $237.78 | $279.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.55 / $181.32 / $279.83
| Professional | | $103.55 | $181.32 | $279.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.27 / $507.19 / $821.70
| Facility | | $293.27 | $507.19 | $821.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.54 / $129.56 / $170.00
| Professional | | $114.54 | $129.56 | $170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.22 / $183.55 / $246.97
| Professional | | $142.22 | $183.55 | $246.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.73 / $137.33 / $245.89
| Professional | | $83.73 | $137.33 | $245.89 |