- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.23 / $242.23 / $242.23
| Facility | | $242.23 | $242.23 | $242.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.97 / $181.84 / $242.23
| Professional | | $111.97 | $181.84 | $242.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.84 / $167.84 / $167.84
| Professional | | $167.84 | $167.84 | $167.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.13 / $158.20 / $191.47
| Professional | | $120.13 | $158.20 | $191.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.41 / $243.30 / $286.23
| Professional | | $194.41 | $243.30 | $286.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.97 / $224.68 / $325.24
| Professional | | $168.97 | $224.68 | $325.24 |