- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.80 / $162.80 / $162.80
| Facility | | $162.80 | $162.80 | $162.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.75 / $153.83 / $209.96
| Professional | | $130.75 | $153.83 | $209.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.85 / $377.87 / $413.21
| Facility | | $305.85 | $377.87 | $413.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $206.10 / $293.47
| Professional | | $144.27 | $206.10 | $293.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.50 / $258.50 / $395.80
| Professional | | $258.50 | $258.50 | $395.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.92 / $164.16 / $258.02
| Professional | | $111.92 | $164.16 | $258.02 |