- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.36 / $190.36 / $190.36
| Facility | | $190.36 | $190.36 | $190.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.11 / $190.36 / $190.36
| Professional | | $90.11 | $190.36 | $190.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.26 / $116.26 / $116.26
| Professional | | $116.26 | $116.26 | $116.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.54 / $140.54 / $209.91
| Facility | | $140.54 | $140.54 | $209.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.59 / $102.59 / $243.38
| Professional | | $102.59 | $102.59 | $243.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.38 / $93.57 / $144.96
| Professional | | $62.38 | $93.57 | $144.96 |