- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.38 / $192.38 / $192.38
| Facility | | $192.38 | $192.38 | $192.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.27 / $210.10 / $265.48
| Professional | | $186.27 | $210.10 | $265.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.62 / $241.80 / $273.23
| Professional | | $217.62 | $241.80 | $273.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.54 / $274.39 / $581.84
| Professional | | $168.54 | $274.39 | $581.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.01 / $255.40 / $477.54
| Professional | | $207.01 | $255.40 | $477.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.91 / $223.47 / $461.31
| Professional | | $143.91 | $223.47 | $461.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.32 / $183.96 / $308.81
| Professional | | $174.32 | $183.96 | $308.81 |