- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.59 / $235.14 / $428.38
| Facility | | $176.59 | $235.14 | $428.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.08 / $177.56 / $287.33
| Professional | | $152.08 | $177.56 | $287.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Professional | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.39 / $240.85 / $262.27
| Facility | | $180.39 | $240.85 | $262.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.96 / $176.00 / $186.90
| Professional | | $147.96 | $176.00 | $186.90 |