- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.50 / $125.50 / $207.08
| Facility | | $125.50 | $125.50 | $207.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.50 / $125.50 / $125.50
| Professional | | $125.50 | $125.50 | $125.50 |
- 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
- $137.94 / $137.94 / $137.94
| Professional | | $137.94 | $137.94 | $137.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.50 / $532.45 / $532.45
| Facility | | $167.50 | $532.45 | $532.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.65 / $147.65 / $174.23
| Professional | | $147.65 | $147.65 | $174.23 |