- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.65 / $243.65 / $248.36
| Facility | | $243.65 | $243.65 | $248.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.11 / $207.66 / $248.36
| Professional | | $185.11 | $207.66 | $248.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.31 / $298.83 / $468.82
| Professional | | $244.31 | $298.83 | $468.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.23 / $187.02 / $232.57
| Professional | | $143.23 | $187.02 | $232.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.33 / $303.47 / $387.59
| Professional | | $233.33 | $303.47 | $387.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.24 / $271.24 / $380.13
| Professional | | $187.24 | $271.24 | $380.13 |