- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.97 / $130.97 / $130.97
| Facility | | $130.97 | $130.97 | $130.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.67 / $128.08 / $162.18
| Professional | | $106.67 | $128.08 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.84 / $314.33 / $349.26
| Facility | | $249.84 | $314.33 | $349.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.16 / $174.52 / $236.10
| Professional | | $122.16 | $174.52 | $236.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.08 / $208.08 / $208.08
| Professional | | $208.08 | $208.08 | $208.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.11 / $126.97 / $210.52
| Professional | | $103.11 | $126.97 | $210.52 |