- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.52 / $164.52 / $164.52
| Facility | | $164.52 | $164.52 | $164.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.55 / $164.52 / $164.52
| Professional | | $83.55 | $164.52 | $164.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.66 / $145.66 / $145.66
| Professional | | $145.66 | $145.66 | $145.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.73 / $67.73 / $194.68
| Facility | | $67.73 | $67.73 | $194.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.58 / $67.73 / $186.28
| Professional | | $57.58 | $67.73 | $186.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.85 / $97.63 / $134.41
| Professional | | $57.85 | $97.63 | $134.41 |