- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.67 / $175.67 / $175.67
| Facility | | $175.67 | $175.67 | $175.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.85 / $175.67 / $201.34
| Professional | | $162.85 | $175.67 | $201.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.50 / $292.38 / $413.28
| Professional | | $213.50 | $292.38 | $413.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.94 / $273.94 / $273.94
| Professional | | $273.94 | $273.94 | $273.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.67 / $193.41 / $295.13
| Facility | | $175.67 | $193.41 | $295.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.61 / $290.10 / $345.19
| Professional | | $183.61 | $290.10 | $345.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.39 / $334.39 / $547.41
| Professional | | $186.39 | $334.39 | $547.41 |