- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.22 / $183.22 / $183.22
| Facility | | $183.22 | $183.22 | $183.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.78 / $145.46 / $513.46
| Professional | | $113.78 | $145.46 | $513.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.35 / $178.32 / $273.92
| Professional | | $125.35 | $178.32 | $273.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.71 / $194.83 / $337.92
| Professional | | $146.71 | $194.83 | $337.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.16 / $209.11 / $372.20
| Professional | | $162.16 | $209.11 | $372.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.51 / $277.37 / $373.38
| Professional | | $187.51 | $277.37 | $373.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.35 / $196.67 / $289.61
| Professional | | $133.35 | $196.67 | $289.61 |