- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.97 / $185.97 / $185.97
| Facility | | $185.97 | $185.97 | $185.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.03 / $185.97 / $185.97
| Professional | | $88.03 | $185.97 | $185.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.47 / $153.47 / $153.47
| Professional | | $153.47 | $153.47 | $153.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.06 / $120.06 / $185.60
| Facility | | $120.06 | $120.06 | $185.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.64 / $120.06 / $162.52
| Professional | | $87.64 | $120.06 | $162.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.41 / $84.62 / $130.82
| Professional | | $56.41 | $84.62 | $130.82 |