- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.61 / $117.61 / $117.61
| Facility | | $117.61 | $117.61 | $117.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.61 / $164.06 / $215.88
| Professional | | $117.61 | $164.06 | $215.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.51 / $215.87 / $345.48
| Facility | | $199.51 | $215.87 | $345.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $157.59 / $302.51
| Professional | | $157.59 | $157.59 | $302.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.62 / $317.83 / $452.58
| Professional | | $315.62 | $317.83 | $452.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.38 / $345.48 / $345.48
| Professional | | $337.38 | $345.48 | $345.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.62 / $174.31 / $345.48
| Professional | | $155.62 | $174.31 | $345.48 |