- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.71 / $186.71 / $186.71
| Facility | | $186.71 | $186.71 | $186.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.37 / $162.13 / $186.71
| Professional | | $157.37 | $162.13 | $186.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.84 / $253.59 / $298.33
| Professional | | $208.84 | $253.59 | $298.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.86 / $164.86 / $164.86
| Professional | | $164.86 | $164.86 | $164.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.09 / $203.16 / $934.12
| Facility | | $158.09 | $203.16 | $934.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.41 / $236.95 / $333.89
| Professional | | $202.41 | $236.95 | $333.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.24 / $235.35 / $312.33
| Professional | | $200.24 | $235.35 | $312.33 |