- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.67 / $186.67 / $186.67
| Facility | | $186.67 | $186.67 | $186.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.81 / $186.67 / $186.67
| Professional | | $94.81 | $186.67 | $186.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.28 / $165.28 / $165.28
| Professional | | $165.28 | $165.28 | $165.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $138.76 / $236.44
| Facility | | $138.76 | $138.76 | $236.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $138.76 / $207.04
| Professional | | $101.29 | $138.76 | $207.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.68 / $251.68 / $296.08
| Facility | | $251.68 | $251.68 | $296.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.86 / $110.79 / $170.72
| Professional | | $73.86 | $110.79 | $170.72 |