- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.62 / $146.62 / $592.79
| Facility | | $146.62 | $146.62 | $592.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.41 / $146.62 / $146.62
| Professional | | $101.41 | $146.62 | $146.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.97 / $151.97 / $151.97
| Facility | | $151.97 | $151.97 | $151.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.97 / $151.97 / $151.97
| Professional | | $151.97 | $151.97 | $151.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.62 / $161.28 / $197.94
| Facility | | $146.62 | $161.28 | $197.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.10 / $107.62 / $183.27
| Professional | | $86.10 | $107.62 | $183.27 |