- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.33 / $258.33 / $258.33
| Facility | | $258.33 | $258.33 | $258.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.16 / $282.08 / $347.23
| Professional | | $251.16 | $282.08 | $347.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.18 / $309.48 / $355.90
| Professional | | $222.18 | $309.48 | $355.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.38 / $374.14 / $790.79
| Professional | | $226.38 | $374.14 | $790.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.52 / $336.64 / $641.22
| Professional | | $272.52 | $336.64 | $641.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.33 / $308.52 / $682.43
| Professional | | $225.33 | $308.52 | $682.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.14 / $264.60 / $415.20
| Professional | | $234.14 | $264.60 | $415.20 |