- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $243.38
| Facility | | $166.31 | $166.31 | $243.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.31 / $243.38 / $243.38
| Professional | | $166.31 | $243.38 | $243.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.93 / $122.93 / $122.93
| Facility | | $122.93 | $122.93 | $122.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.93 / $122.93 / $122.93
| Professional | | $122.93 | $122.93 | $122.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $202.82
| Professional | | $172.40 | $172.40 | $202.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.71 / $202.82 / $263.67
| Professional | | $194.71 | $202.82 | $263.67 |