- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.03 / $183.03 / $183.03
| Facility | | $183.03 | $183.03 | $183.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.96 / $183.03 / $183.03
| Professional | | $92.96 | $183.03 | $183.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.27 / $144.27 / $144.27
| Professional | | $144.27 | $144.27 | $144.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.85 / $140.85 / $217.74
| Facility | | $140.85 | $140.85 | $217.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.82 / $102.82 / $252.38
| Professional | | $102.82 | $102.82 | $252.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.42 / $108.63 / $167.39
| Professional | | $72.42 | $108.63 | $167.39 |