- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $208.93
| Facility | | $144.54 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $151.36 / $218.78
| Professional | | $95.50 | $151.36 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Professional | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $229.09 / $251.19
| Professional | | $177.83 | $229.09 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $208.93 / $263.03
| Professional | | $190.55 | $208.93 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $173.78 / $263.03
| Professional | | $87.10 | $173.78 | $263.03 |