- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.88 / $203.88 / $203.88
| Facility | | $203.88 | $203.88 | $203.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.55 / $203.88 / $203.88
| Professional | | $103.55 | $203.88 | $203.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.52 / $180.52 / $180.52
| Professional | | $180.52 | $180.52 | $180.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.89 / $170.89 / $264.14
| Facility | | $170.89 | $170.89 | $264.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.75 / $170.89 / $231.30
| Professional | | $124.75 | $170.89 | $231.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.31 / $121.00 / $161.22
| Professional | | $67.31 | $121.00 | $161.22 |