- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.20 / $460.20 / $603.22
| Facility | | $460.20 | $460.20 | $603.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.28 / $113.28 / $120.36
| Professional | | $113.28 | $113.28 | $120.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $125.08 / $132.16
| Facility | | $120.36 | $125.08 | $132.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.44 / $127.44 / $127.44
| Professional | | $127.44 | $127.44 | $127.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Facility | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $120.36 / $120.36
| Professional | | $120.36 | $120.36 | $120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.00 / $118.00 / $118.00
| Professional | | $118.00 | $118.00 | $118.00 |