- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.94 / $196.74 / $196.74
| Facility | | $159.94 | $196.74 | $196.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.81 / $159.94 / $196.74
| Professional | | $126.81 | $159.94 | $196.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.37 / $153.28 / $217.82
| Professional | | $113.37 | $153.28 | $217.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.26 / $141.26 / $141.26
| Professional | | $141.26 | $141.26 | $141.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.06 / $206.58 / $449.46
| Facility | | $138.06 | $206.58 | $449.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.33 / $1,009.33 / $1,009.33
| Professional | | $1,009.33 | $1,009.33 | $1,009.33 |