- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.43 / $114.43 / $114.43
| Facility | | $114.43 | $114.43 | $114.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.53 / $114.43 / $114.43
| Professional | | $83.53 | $114.43 | $114.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.75 / $126.75 / $158.44
| Professional | | $126.75 | $126.75 | $158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.75 / $126.75 / $158.44
| Professional | | $126.75 | $126.75 | $158.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.38 / $74.38 / $74.38
| Facility | | $74.38 | $74.38 | $74.38 |