- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.71 / $177.71 / $177.71
| Facility | | $177.71 | $177.71 | $177.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.25 / $177.71 / $177.71
| Professional | | $90.25 | $177.71 | $177.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.34 / $157.34 / $157.34
| Professional | | $157.34 | $157.34 | $157.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $166.47 / $249.27
| Facility | | $166.47 | $166.47 | $249.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.52 / $166.47 / $218.27
| Professional | | $121.52 | $166.47 | $218.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.31 / $105.47 / $169.99
| Professional | | $70.31 | $105.47 | $169.99 |