- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.56 / $194.56 / $194.56
| Facility | | $194.56 | $194.56 | $194.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.82 / $194.56 / $194.56
| Professional | | $98.82 | $194.56 | $194.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.27 / $172.27 / $172.27
| Professional | | $172.27 | $172.27 | $172.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.22 / $159.22 / $246.14
| Facility | | $159.22 | $159.22 | $246.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.23 / $159.22 / $215.53
| Professional | | $116.23 | $159.22 | $215.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.45 / $115.48 / $172.12
| Professional | | $74.45 | $115.48 | $172.12 |