- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.68 / $208.68 / $208.68
| Facility | | $208.68 | $208.68 | $208.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.78 / $208.68 / $208.68
| Professional | | $98.78 | $208.68 | $208.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.21 / $172.21 / $172.21
| Professional | | $172.21 | $172.21 | $172.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.23 / $166.23 / $256.98
| Facility | | $166.23 | $166.23 | $256.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.35 / $166.23 / $225.02
| Professional | | $121.35 | $166.23 | $225.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.95 / $115.43 / $173.88
| Professional | | $76.95 | $115.43 | $173.88 |