- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.86 / $182.86 / $182.86
| Facility | | $182.86 | $182.86 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.92 / $182.86 / $182.86
| Professional | | $108.92 | $182.86 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.00 / $164.96 / $194.00
| Professional | | $92.00 | $164.96 | $194.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.84 / $179.84 / $179.84
| Professional | | $179.84 | $179.84 | $179.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $90.00 / $100.00
| Facility | | $64.00 | $90.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.28 / $135.28 / $135.28
| Professional | | $135.28 | $135.28 | $135.28 |