- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.07 / $184.97 / $193.65
| Facility | | $155.07 | $184.97 | $193.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $103.52 / $103.52
| Professional | | $103.52 | $103.52 | $103.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.53 / $393.18 / $622.85
| Facility | | $103.53 | $393.18 | $622.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.40 / $95.20 / $461.13
| Professional | | $71.40 | $95.20 | $461.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.65 / $58.65 / $58.65
| Professional | | $58.65 | $58.65 | $58.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $113.87 / $210.15
| Facility | | $100.00 | $113.87 | $210.15 |