- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.08 / $234.08 / $234.08
| Facility | | $234.08 | $234.08 | $234.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.88 / $234.08 / $234.08
| Professional | | $118.88 | $234.08 | $234.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.51 / $184.51 / $184.51
| Professional | | $184.51 | $184.51 | $184.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.64 / $177.64 / $371.28
| Facility | | $177.64 | $177.64 | $371.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.68 / $177.64 / $325.10
| Professional | | $129.68 | $177.64 | $325.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.62 / $138.91 / $214.08
| Professional | | $92.62 | $138.91 | $214.08 |