- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.86 / $299.58 / $478.42
| Facility | | $195.86 | $299.58 | $478.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.56 / $177.56 / $177.56
| Professional | | $177.56 | $177.56 | $177.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.87 / $261.97 / $442.97
| Professional | | $158.87 | $261.97 | $442.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Facility | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.93 / $150.93 / $177.56
| Professional | | $150.93 | $150.93 | $177.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.19 / $176.00 / $224.28
| Professional | | $154.19 | $176.00 | $224.28 |