- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.50 / $260.11 / $260.11
| Facility | | $125.50 | $260.11 | $260.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.50 / $125.50 / $125.50
| Professional | | $125.50 | $125.50 | $125.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.49 / $106.49 / $106.49
| Professional | | $106.49 | $106.49 | $106.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.94 / $137.94 / $137.94
| Facility | | $137.94 | $137.94 | $137.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.90 / $203.90 / $203.90
| Professional | | $203.90 | $203.90 | $203.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.16 / $147.65 / $192.18
| Professional | | $146.16 | $147.65 | $192.18 |