- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.56 / $151.56 / $151.56
| Facility | | $151.56 | $151.56 | $151.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.16 / $151.56 / $151.56
| Professional | | $129.16 | $151.56 | $151.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.27 / $408.70 / $510.88
| Professional | | $388.27 | $408.70 | $510.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.87 / $342.87 / $555.72
| Professional | | $342.87 | $342.87 | $555.72 |