- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.61 / $251.61 / $251.61
| Facility | | $251.61 | $251.61 | $251.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.10 / $251.61 / $251.61
| Professional | | $119.10 | $251.61 | $251.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.83 / $184.83 / $184.83
| Professional | | $184.83 | $184.83 | $184.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.32 / $174.32 / $278.97
| Facility | | $174.32 | $174.32 | $278.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.25 / $174.32 / $244.28
| Professional | | $127.25 | $174.32 | $244.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.78 / $139.18 / $209.65
| Professional | | $92.78 | $139.18 | $209.65 |