- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.52 / $131.52 / $131.52
| Facility | | $131.52 | $131.52 | $131.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.52 / $183.86 / $235.97
| Professional | | $131.52 | $183.86 | $235.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.47 / $297.81 / $357.90
| Facility | | $231.47 | $297.81 | $357.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.40 / $217.40 / $313.39
| Professional | | $217.40 | $217.40 | $313.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.97 / $329.27 / $468.85
| Professional | | $326.97 | $329.27 | $468.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.51 / $357.90 / $357.90
| Professional | | $349.51 | $357.90 | $357.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.33 / $191.31 / $328.57
| Professional | | $164.33 | $191.31 | $328.57 |