- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.72 / $128.72 / $128.72
| Facility | | $128.72 | $128.72 | $128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.72 / $156.41 / $294.43
| Professional | | $128.72 | $156.41 | $294.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.73 / $243.19 / $350.26
| Facility | | $202.73 | $243.19 | $350.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.53 / $177.53 / $306.70
| Professional | | $177.53 | $177.53 | $306.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.00 / $322.24 / $458.84
| Professional | | $320.00 | $322.24 | $458.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.05 / $350.26 / $350.26
| Professional | | $342.05 | $350.26 | $350.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.94 / $176.65 / $291.24
| Professional | | $157.94 | $176.65 | $291.24 |