- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.12 / $161.28 / $161.28
| Facility | | $131.12 | $161.28 | $161.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.99 / $131.12 / $161.28
| Professional | | $110.99 | $131.12 | $161.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.53 / $186.53 / $235.66
| Professional | | $134.53 | $186.53 | $235.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.33 / $190.33 / $190.33
| Professional | | $190.33 | $190.33 | $190.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.33 / $169.34 / $368.45
| Facility | | $117.33 | $169.34 | $368.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.03 / $850.03 / $850.03
| Professional | | $850.03 | $850.03 | $850.03 |