- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.75 / $146.75 / $146.75
| Facility | | $146.75 | $146.75 | $146.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.30 / $146.30 / $146.75
| Professional | | $146.30 | $146.30 | $146.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.59 / $222.98 / $228.53
| Professional | | $188.59 | $222.98 | $228.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.13 / $246.57 / $310.04
| Professional | | $244.13 | $246.57 | $310.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.07 / $146.75 / $1,062.92
| Facility | | $105.07 | $146.75 | $1,062.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.36 / $100.63 / $167.71
| Professional | | $80.36 | $100.63 | $167.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.08 / $100.63 / $167.71
| Professional | | $67.08 | $100.63 | $167.71 |