- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.72 / $176.72 / $240.66
| Facility | | $176.72 | $176.72 | $240.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.43 / $239.46 / $609.51
| Professional | | $158.43 | $239.46 | $609.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.24 / $350.21 / $483.05
| Professional | | $294.24 | $350.21 | $483.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.83 / $297.58 / $524.54
| Professional | | $196.83 | $297.58 | $524.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.64 / $317.52 / $585.54
| Professional | | $200.64 | $317.52 | $585.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.64 / $367.78 / $805.08
| Professional | | $274.64 | $367.78 | $805.08 |