- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.12 / $287.12 / $287.12
| Facility | | $287.12 | $287.12 | $287.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.91 / $186.86 / $287.12
| Professional | | $135.91 | $186.86 | $287.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.91 / $186.91 / $186.91
| Professional | | $186.91 | $186.91 | $186.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.75 / $176.75 / $316.64
| Facility | | $176.75 | $176.75 | $316.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.03 / $176.75 / $303.01
| Professional | | $129.03 | $176.75 | $303.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.08 / $141.11 / $218.64
| Professional | | $94.08 | $141.11 | $218.64 |