- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.41 / $247.41 / $247.41
| Facility | | $247.41 | $247.41 | $247.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.66 / $247.41 / $247.41
| Professional | | $125.66 | $247.41 | $247.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.06 / $219.06 / $219.06
| Professional | | $219.06 | $219.06 | $219.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.52 / $166.52 / $325.04
| Facility | | $166.52 | $166.52 | $325.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $166.52 / $284.62
| Professional | | $121.56 | $166.52 | $284.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.64 / $146.83 / $204.88
| Professional | | $88.64 | $146.83 | $204.88 |