- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.44 / $128.44 / $128.44
| Facility | | $128.44 | $128.44 | $128.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.44 / $156.09 / $227.22
| Professional | | $128.44 | $156.09 | $227.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $349.53
| Facility | | $231.66 | $231.66 | $349.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $169.11 / $306.06
| Professional | | $169.11 | $169.11 | $306.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.32 / $321.57 / $457.88
| Professional | | $319.32 | $321.57 | $457.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.34 / $349.53 / $349.53
| Professional | | $341.34 | $349.53 | $349.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.60 / $181.40 / $320.89
| Professional | | $157.60 | $181.40 | $320.89 |