- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.77 / $181.77 / $181.77
| Facility | | $181.77 | $181.77 | $181.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.55 / $163.98 / $218.91
| Professional | | $135.55 | $163.98 | $218.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.75 / $176.50 / $221.93
| Professional | | $174.75 | $176.50 | $221.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.49 / $181.77 / $309.01
| Facility | | $148.49 | $181.77 | $309.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.86 / $339.37 / $1,105.55
| Professional | | $185.86 | $339.37 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.86 / $328.97 / $452.61
| Professional | | $185.86 | $328.97 | $452.61 |