- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.82 / $134.82 / $134.82
| Facility | | $134.82 | $134.82 | $134.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.24 / $134.82 / $134.82
| Professional | | $126.24 | $134.82 | $134.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.45 / $189.45 / $189.45
| Professional | | $189.45 | $189.45 | $189.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.71 / $129.72 / $413.03
| Professional | | $100.71 | $129.72 | $413.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.36 / $185.32 / $381.68
| Professional | | $172.36 | $185.32 | $381.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.23 / $195.14 / $423.57
| Professional | | $102.23 | $195.14 | $423.57 |