- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.42 / $427.42 / $427.42
| Facility | | $427.42 | $427.42 | $427.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.69 / $136.02 / $340.35
| Professional | | $101.69 | $136.02 | $340.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.80 / $159.90 / $251.17
| Professional | | $126.80 | $159.90 | $251.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.52 / $227.36 / $345.63
| Professional | | $147.52 | $227.36 | $345.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.16 / $228.37 / $448.04
| Professional | | $145.16 | $228.37 | $448.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.33 / $203.73 / $304.83
| Professional | | $150.33 | $203.73 | $304.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.89 / $125.87 / $185.03
| Professional | | $104.89 | $125.87 | $185.03 |