- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.12 / $391.77 / $942.47
| Facility | | $276.12 | $391.77 | $942.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.23 / $144.32 / $156.21
| Professional | | $124.23 | $144.32 | $156.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.53 / $345.42 / $742.10
| Facility | | $217.53 | $345.42 | $742.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $123.00 / $131.19
| Professional | | $123.00 | $123.00 | $131.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.54 / $120.54 / $120.54
| Facility | | $120.54 | $120.54 | $120.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.06 / $466.06 / $466.06
| Professional | | $466.06 | $466.06 | $466.06 |