- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.56 / $185.56 / $185.56
| Facility | | $185.56 | $185.56 | $185.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.84 / $185.56 / $185.56
| Professional | | $87.84 | $185.56 | $185.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.31 / $136.31 / $136.31
| Professional | | $136.31 | $136.31 | $136.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.94 / $142.94 / $243.75
| Facility | | $142.94 | $142.94 | $243.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.35 / $142.94 / $213.44
| Professional | | $104.35 | $142.94 | $213.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.53 / $99.79 / $150.31
| Professional | | $66.53 | $99.79 | $150.31 |