- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.65 / $394.65 / $394.65
| Facility | | $394.65 | $394.65 | $394.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.14 / $97.14 / $103.22
| Professional | | $97.14 | $97.14 | $103.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.22 / $107.26 / $113.33
| Facility | | $103.22 | $107.26 | $113.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.29 / $109.29 / $109.29
| Professional | | $109.29 | $109.29 | $109.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.06 / $101.19 / $101.19
| Professional | | $30.06 | $101.19 | $101.19 |