- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.74 / $160.74 / $160.74
| Facility | | $160.74 | $160.74 | $160.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.74 / $168.61 / $168.61
| Professional | | $160.74 | $168.61 | $168.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.25 / $404.21 / $496.55
| Facility | | $191.25 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.93 / $204.43 / $788.89
| Professional | | $172.93 | $204.43 | $788.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.32 / $189.91 / $341.83
| Professional | | $126.32 | $189.91 | $341.83 |