- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.62 / $186.62 / $186.62
| Facility | | $186.62 | $186.62 | $186.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.94 / $181.97 / $210.23
| Professional | | $161.94 | $181.97 | $210.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.52 / $248.52 / $248.52
| Professional | | $248.52 | $248.52 | $248.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.83 / $186.62 / $256.36
| Professional | | $173.83 | $186.62 | $256.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.02 / $217.02 / $217.02
| Facility | | $217.02 | $217.02 | $217.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.84 / $167.84 / $245.22
| Professional | | $167.84 | $167.84 | $245.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.97 / $205.07 / $319.48
| Professional | | $166.97 | $205.07 | $319.48 |