- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.76 / $246.76 / $246.76
| Facility | | $246.76 | $246.76 | $246.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.81 / $246.76 / $246.76
| Professional | | $116.81 | $246.76 | $246.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.63 / $203.63 / $203.63
| Professional | | $203.63 | $203.63 | $203.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.96 / $170.96 / $283.97
| Facility | | $170.96 | $170.96 | $283.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.80 / $124.80 / $329.25
| Professional | | $124.80 | $124.80 | $329.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.00 / $135.28 / $205.61
| Professional | | $91.00 | $135.28 | $205.61 |