- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.70 / $203.70 / $203.70
| Facility | | $203.70 | $203.70 | $203.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.78 / $147.72 / $203.70
| Professional | | $133.78 | $147.72 | $203.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $178.13 / $222.44
| Professional | | $135.44 | $178.13 | $222.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.67 / $188.67 / $188.67
| Professional | | $188.67 | $188.67 | $188.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.64 / $179.64 / $179.64
| Professional | | $179.64 | $179.64 | $179.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.87 / $228.72 / $301.91
| Professional | | $154.87 | $228.72 | $301.91 |