- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.80 / $170.80 / $170.80
| Facility | | $170.80 | $170.80 | $170.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.38 / $131.12 / $170.80
| Professional | | $130.38 | $131.12 | $170.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.38 / $251.38 / $251.38
| Professional | | $251.38 | $251.38 | $251.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.50 / $131.12 / $216.54
| Facility | | $113.50 | $131.12 | $216.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.03 / $850.03 / $850.03
| Professional | | $850.03 | $850.03 | $850.03 |