- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.40 / $154.40 / $154.40
| Facility | | $154.40 | $154.40 | $154.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.40 / $187.62 / $327.92
| Professional | | $154.40 | $187.62 | $327.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $420.15
| Facility | | $373.38 | $373.38 | $420.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.37 / $317.37 / $487.13
| Professional | | $317.37 | $317.37 | $487.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.82 / $386.54 / $550.40
| Professional | | $383.82 | $386.54 | $550.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.37 / $194.37 / $279.47
| Professional | | $194.37 | $194.37 | $279.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.44 / $224.58 / $420.15
| Professional | | $189.44 | $224.58 | $420.15 |