- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.22 / $163.44 / $209.77
| Facility | | $144.22 | $163.44 | $209.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.65 / $92.65 / $92.65
| Professional | | $92.65 | $92.65 | $92.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.77 / $209.77 / $209.77
| Professional | | $209.77 | $209.77 | $209.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.24 / $199.33 / $242.55
| Professional | | $166.24 | $199.33 | $242.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.29 / $209.77 / $244.73
| Professional | | $192.29 | $209.77 | $244.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.81 / $262.22 / $262.22
| Professional | | $174.81 | $262.22 | $262.22 |