- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.08 / $181.08 / $181.08
| Facility | | $181.08 | $181.08 | $181.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.72 / $181.08 / $181.08
| Professional | | $85.72 | $181.08 | $181.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.44 / $149.44 / $149.44
| Professional | | $149.44 | $149.44 | $149.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.82 / $121.82 / $188.31
| Facility | | $121.82 | $121.82 | $188.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.93 / $121.82 / $164.89
| Professional | | $88.93 | $121.82 | $164.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.68 / $88.03 / $137.90
| Professional | | $58.68 | $88.03 | $137.90 |