- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $119.61
| Facility | | $119.61 | $119.61 | $119.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $161.47
| Professional | | $119.61 | $119.61 | $161.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.03 / $43.72 / $58.82
| Facility | | $36.03 | $43.72 | $58.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Facility | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.26 / $131.35 / $131.35
| Professional | | $104.26 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.28 / $132.53 / $140.74
| Professional | | $117.28 | $132.53 | $140.74 |