- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.52 / $147.52 / $147.52
| Facility | | $147.52 | $147.52 | $147.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $163.75 / $948.55
| Professional | | $88.51 | $163.75 | $948.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.10 / $154.47 / $184.41
| Professional | | $104.10 | $154.47 | $184.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.52 / $147.52 / $147.52
| Facility | | $147.52 | $147.52 | $147.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.77 / $204.03 / $317.89
| Professional | | $89.77 | $204.03 | $317.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.57 / $147.52 / $276.02
| Professional | | $53.57 | $147.52 | $276.02 |