- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.88 / $183.88 / $183.88
| Facility | | $183.88 | $183.88 | $183.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.28 / $148.27 / $214.67
| Professional | | $127.28 | $148.27 | $214.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.07 / $195.50 / $273.42
| Professional | | $151.07 | $195.50 | $273.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.66 / $215.84 / $308.48
| Professional | | $143.66 | $215.84 | $308.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.48 / $206.50 / $316.77
| Professional | | $178.48 | $206.50 | $316.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.28 / $183.88 / $214.67
| Professional | | $127.28 | $183.88 | $214.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.12 / $194.43 / $281.13
| Professional | | $132.12 | $194.43 | $281.13 |