- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.66 / $141.66 / $141.66
| Facility | | $141.66 | $141.66 | $141.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.66 / $141.66 / $141.66
| Professional | | $141.66 | $141.66 | $141.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.55 / $210.55 / $236.61
| Professional | | $210.55 | $210.55 | $236.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.50 / $144.50 / $144.50
| Professional | | $144.50 | $144.50 | $144.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.98 / $224.98 / $687.07
| Professional | | $224.98 | $224.98 | $687.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.11 / $172.67 / $323.26
| Professional | | $115.11 | $172.67 | $323.26 |