- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.66 / $183.66 / $195.29
| Facility | | $183.66 | $183.66 | $195.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.70 / $373.70 / $373.70
| Professional | | $373.70 | $373.70 | $373.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.48 / $47.48 / $52.70
| Facility | | $47.48 | $47.48 | $52.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.44 / $47.48 / $61.76
| Professional | | $42.44 | $47.48 | $61.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.10 / $177.10 / $177.10
| Professional | | $177.10 | $177.10 | $177.10 |