- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.60 / $164.60 / $208.74
| Facility | | $164.60 | $164.60 | $208.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.18 / $164.60 / $210.00
| Professional | | $140.18 | $164.60 | $210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.15 / $187.15 / $187.15
| Professional | | $187.15 | $187.15 | $187.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.41 / $175.41 / $175.41
| Professional | | $175.41 | $175.41 | $175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.38 / $168.38 / $168.38
| Professional | | $168.38 | $168.38 | $168.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.13 / $187.04 / $187.09
| Professional | | $155.13 | $187.04 | $187.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $135.00 / $135.00
| Professional | | $135.00 | $135.00 | $135.00 |