- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.68 / $203.68 / $203.68
| Facility | | $203.68 | $203.68 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.42 / $203.68 / $203.68
| Professional | | $96.42 | $203.68 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.63 / $149.63 / $149.63
| Professional | | $149.63 | $149.63 | $149.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.12 / $141.12 / $225.84
| Facility | | $141.12 | $141.12 | $225.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.02 / $103.02 / $261.75
| Professional | | $103.02 | $103.02 | $261.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.50 / $150.50 / $150.50
| Facility | | $150.50 | $150.50 | $150.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.11 / $111.66 / $169.72
| Professional | | $75.11 | $111.66 | $169.72 |