- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.02 / $232.36 / $298.20
| Facility | | $205.02 | $232.36 | $298.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.20 / $298.20 / $298.20
| Professional | | $298.20 | $298.20 | $298.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.20 / $280.82 / $310.64
| Professional | | $234.20 | $280.82 | $310.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.36 / $298.20 / $347.91
| Professional | | $273.36 | $298.20 | $347.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.51 / $298.20 / $372.77
| Professional | | $248.51 | $298.20 | $372.77 |