- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $125.89 / $218.78
| Professional | | $104.71 | $125.89 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $478.63
| Facility | | $354.81 | $354.81 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $1,071.52
| Professional | | $407.38 | $407.38 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $389.05
| Facility | | $199.53 | $199.53 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $309.03 / $407.38
| Professional | | $128.82 | $309.03 | $407.38 |