- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $147.91 / $151.36
| Professional | | $144.54 | $147.91 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $288.40 / $288.40
| Facility | | $151.36 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $812.83
| Professional | | $151.36 | $151.36 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $181.97
| Professional | | $181.97 | $181.97 | $181.97 |