- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.26 / $192.26 / $192.26
| Facility | | $192.26 | $192.26 | $192.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.26 / $206.17 / $206.17
| Professional | | $192.26 | $206.17 | $206.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.08 / $292.13 / $299.39
| Professional | | $247.08 | $292.13 | $299.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.38 / $288.23 / $362.43
| Professional | | $285.38 | $288.23 | $362.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.82 / $201.94 / $1,155.73
| Facility | | $124.82 | $201.94 | $1,155.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $167.54 / $213.70
| Professional | | $102.33 | $167.54 | $213.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.45 / $111.70 / $210.54
| Professional | | $74.45 | $111.70 | $210.54 |