- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.44 / $165.44 / $165.44
| Facility | | $165.44 | $165.44 | $165.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.94 / $168.94 / $193.42
| Professional | | $143.94 | $168.94 | $193.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.05 / $202.05 / $208.15
| Professional | | $202.05 | $202.05 | $208.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $188.16
| Professional | | $141.06 | $141.06 | $188.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.62 / $173.60 / $230.29
| Facility | | $140.62 | $173.60 | $230.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.32 / $139.56 / $171.26
| Professional | | $108.32 | $139.56 | $171.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.47 / $202.50 / $281.51
| Professional | | $158.47 | $202.50 | $281.51 |