- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.04 / $111.04 / $111.04
| Facility | | $111.04 | $111.04 | $111.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.65 / $111.04 / $139.38
| Professional | | $106.65 | $111.04 | $139.38 |
- 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
- $111.04 / $172.11 / $210.98
| Facility | | $111.04 | $172.11 | $210.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.18 / $216.18 / $216.18
| Facility | | $216.18 | $216.18 | $216.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.53 / $204.16 / $204.16
| Professional | | $190.53 | $204.16 | $204.16 |