- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.36 / $177.11 / $177.11
| Facility | | $155.36 | $177.11 | $177.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.01 / $165.44 / $207.76
| Professional | | $115.01 | $165.44 | $207.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.97 / $195.21 / $307.44
| Professional | | $147.97 | $195.21 | $307.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.94 / $177.11 / $271.88
| Facility | | $143.94 | $177.11 | $271.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.36 / $201.97 / $307.61
| Professional | | $155.36 | $201.97 | $307.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.46 / $255.50 / $469.18
| Professional | | $206.46 | $255.50 | $469.18 |