- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.94 / $122.94 / $184.41
| Facility | | $122.94 | $122.94 | $184.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $122.94 / $173.36
| Professional | | $110.00 | $122.94 | $173.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.06 / $162.06 / $162.06
| Facility | | $162.06 | $162.06 | $162.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.47 / $72.45 / $235.08
| Facility | | $37.47 | $72.45 | $235.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.94 / $118.94 / $148.68
| Professional | | $118.94 | $118.94 | $148.68 |