- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.60 / $161.60 / $161.60
| Facility | | $161.60 | $161.60 | $161.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.62 / $161.60 / $161.60
| Professional | | $148.62 | $161.60 | $161.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.83 / $265.75 / $289.67
| Professional | | $194.83 | $265.75 | $289.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.74 / $262.02 / $678.76
| Professional | | $111.74 | $262.02 | $678.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.91 / $337.37 / $337.37
| Professional | | $138.91 | $337.37 | $337.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.67 / $245.79 / $488.83
| Professional | | $187.67 | $245.79 | $488.83 |