- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.72 / $130.72 / $130.72
| Facility | | $130.72 | $130.72 | $130.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $166.28 / $227.67
| Professional | | $130.72 | $166.28 | $227.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.66 / $271.68 / $355.75
| Facility | | $212.66 | $271.68 | $355.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $198.33 / $311.51
| Professional | | $198.33 | $198.33 | $311.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.00 / $327.29 / $466.03
| Professional | | $325.00 | $327.29 | $466.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.41 / $355.75 / $355.75
| Professional | | $347.41 | $355.75 | $355.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.40 / $212.24 / $355.75
| Professional | | $160.40 | $212.24 | $355.75 |