- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $131.72 / $131.72
| Facility | | $131.72 | $131.72 | $131.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $131.72 / $132.65
| Professional | | $106.45 | $131.72 | $132.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.77 / $517.53 / $517.53
| Facility | | $462.77 | $517.53 | $517.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $197.58 / $243.68
| Facility | | $131.72 | $197.58 | $243.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.33 / $155.00 / $155.00
| Facility | | $151.33 | $155.00 | $155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $143.72 / $143.72
| Professional | | $134.13 | $143.72 | $143.72 |