- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.25 / $193.25 / $193.25
| Facility | | $193.25 | $193.25 | $193.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.35 / $193.25 / $223.52
| Professional | | $137.35 | $193.25 | $223.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.84 / $179.84 / $179.84
| Professional | | $179.84 | $179.84 | $179.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.74 / $159.74 / $159.74
| Facility | | $159.74 | $159.74 | $159.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.78 / $135.78 / $164.53
| Professional | | $135.78 | $135.78 | $164.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.17 / $112.76 / $165.82
| Professional | | $75.17 | $112.76 | $165.82 |