- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.01 / $272.29 / $519.37
| Facility | | $61.01 | $272.29 | $519.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.05 / $290.20 / $422.72
| Professional | | $137.05 | $290.20 | $422.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.97 / $339.20 / $422.72
| Facility | | $240.97 | $339.20 | $422.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.20 / $422.72 / $438.06
| Professional | | $339.20 | $422.72 | $438.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.04 / $208.04 / $336.06
| Professional | | $192.04 | $208.04 | $336.06 |