- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.50 / $154.50 / $246.23
| Facility | | $154.50 | $154.50 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.80 / $176.22 / $246.23
| Professional | | $152.80 | $176.22 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.63 / $213.63 / $213.63
| Facility | | $213.63 | $213.63 | $213.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.63 / $213.63 / $213.63
| Professional | | $213.63 | $213.63 | $213.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.78 / $190.78 / $190.78
| Facility | | $190.78 | $190.78 | $190.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.27 / $139.27 / $190.78
| Professional | | $139.27 | $139.27 | $190.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.76 / $130.88 / $205.31
| Professional | | $86.76 | $130.88 | $205.31 |