- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.42 / $381.42 / $381.42
| Facility | | $381.42 | $381.42 | $381.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $122.05
| Professional | | $117.36 | $117.36 | $122.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.19 / $117.19 / $123.82
| Facility | | $117.19 | $117.19 | $123.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.72 / $117.36 / $117.36
| Facility | | $110.72 | $117.36 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |