- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.25 / $147.25 / $147.25
| Facility | | $147.25 | $147.25 | $147.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.69 / $147.25 / $177.70
| Professional | | $134.69 | $147.25 | $177.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.14 / $271.14 / $403.69
| Professional | | $271.14 | $271.14 | $403.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.25 / $250.33 / $272.55
| Facility | | $147.25 | $250.33 | $272.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.41 / $411.81 / $1,308.32
| Professional | | $238.41 | $411.81 | $1,308.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.42 / $390.13 / $547.66
| Professional | | $219.42 | $390.13 | $547.66 |