- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.36 / $132.36 / $132.36
| Facility | | $132.36 | $132.36 | $132.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.48 / $132.36 / $132.36
| Professional | | $22.48 | $132.36 | $132.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.07 / $147.07 / $151.47
| Professional | | $147.07 | $147.07 | $151.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.96 / $130.16 / $403.63
| Professional | | $109.96 | $130.16 | $403.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.44 / $307.27 / $307.27
| Professional | | $129.44 | $307.27 | $307.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.54 / $136.82 / $372.87
| Professional | | $97.54 | $136.82 | $372.87 |