- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.06 / $336.06 / $336.06
| Facility | | $336.06 | $336.06 | $336.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.02 / $84.02 / $84.02
| Professional | | $84.02 | $84.02 | $84.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.81 / $72.81 / $72.81
| Facility | | $72.81 | $72.81 | $72.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.44 / $128.44 / $160.55
| Professional | | $128.44 | $128.44 | $160.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.81 / $72.81 / $72.81
| Facility | | $72.81 | $72.81 | $72.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.86 / $112.02 / $112.02
| Professional | | $91.86 | $112.02 | $112.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.05 / $47.05 / $67.20
| Professional | | $47.05 | $47.05 | $67.20 |