- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.16 / $156.16 / $156.16
| Facility | | $156.16 | $156.16 | $156.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.16 / $156.16 / $162.97
| Professional | | $156.16 | $156.16 | $162.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.61 / $218.36 / $218.36
| Professional | | $185.61 | $218.36 | $218.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $153.75 / $153.75
| Facility | | $153.75 | $153.75 | $153.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.28 / $195.58 / $218.36
| Professional | | $179.28 | $195.58 | $218.36 |