- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.65 / $159.65 / $159.65
| Facility | | $159.65 | $159.65 | $159.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.65 / $159.65 / $159.65
| Professional | | $159.65 | $159.65 | $159.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.42 / $303.42 / $303.42
| Professional | | $303.42 | $303.42 | $303.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $410.22
| Professional | | $410.22 | $410.22 | $410.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.68 / $173.68 / $549.83
| Professional | | $173.68 | $173.68 | $549.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.54 / $183.22 / $348.81
| Professional | | $109.54 | $183.22 | $348.81 |