- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.58 / $311.58 / $311.58
| Facility | | $311.58 | $311.58 | $311.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.50 / $311.58 / $311.58
| Professional | | $147.50 | $311.58 | $311.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.84 / $205.84 / $205.84
| Professional | | $205.84 | $205.84 | $205.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.87 / $215.87 / $383.40
| Facility | | $215.87 | $215.87 | $383.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $215.87 / $335.71
| Professional | | $157.59 | $215.87 | $335.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.90 / $170.82 / $259.63
| Professional | | $114.90 | $170.82 | $259.63 |