- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.61 / $212.61 / $212.61
| Facility | | $212.61 | $212.61 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.47 / $212.61 / $212.61
| Professional | | $176.47 | $212.61 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.38 / $186.38 / $232.97
| Professional | | $186.38 | $186.38 | $232.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.23 / $286.26 / $524.29
| Facility | | $243.23 | $286.26 | $524.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $198.33
| Professional | | $180.30 | $180.30 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.71 / $224.71 / $332.51
| Professional | | $224.71 | $224.71 | $332.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $198.33
| Professional | | $180.30 | $180.30 | $198.33 |