- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.35 / $193.35 / $193.35
| Facility | | $193.35 | $193.35 | $193.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.20 / $193.35 / $193.35
| Professional | | $98.20 | $193.35 | $193.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.41 / $152.41 / $152.41
| Professional | | $152.41 | $152.41 | $152.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.58 / $175.58 / $258.63
| Facility | | $175.58 | $175.58 | $258.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $175.58 / $226.47
| Professional | | $128.16 | $175.58 | $226.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.34 / $114.76 / $160.29
| Professional | | $69.34 | $114.76 | $160.29 |