- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.72 / $206.72 / $206.72
| Facility | | $206.72 | $206.72 | $206.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.72 / $206.72 / $206.72
| Professional | | $206.72 | $206.72 | $206.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.08 / $118.08 / $227.89
| Facility | | $118.08 | $118.08 | $227.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.81 / $57.57 / $162.94
| Professional | | $51.81 | $57.57 | $162.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.87 / $155.87 / $155.87
| Professional | | $155.87 | $155.87 | $155.87 |