- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.22 / $130.22 / $130.22
| Facility | | $130.22 | $130.22 | $130.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.22 / $131.01 / $1,166.68
| Professional | | $130.22 | $131.01 | $1,166.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.68 / $252.68 / $252.68
| Facility | | $252.68 | $252.68 | $252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $252.68 / $625.13
| Professional | | $194.10 | $252.68 | $625.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $388.06 / $504.47
| Professional | | $60.00 | $388.06 | $504.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $372.10 / $558.15
| Professional | | $295.60 | $372.10 | $558.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.15 / $201.73 / $289.41
| Professional | | $182.15 | $201.73 | $289.41 |