- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.69 / $104.69 / $104.69
| Facility | | $104.69 | $104.69 | $104.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.23 / $104.69 / $104.69
| Professional | | $102.23 | $104.69 | $104.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.97 / $50.63 / $50.63
| Professional | | $37.97 | $50.63 | $50.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.31 / $86.31 / $111.88
| Facility | | $86.31 | $86.31 | $111.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.31 / $103.57 / $129.46
| Professional | | $86.31 | $103.57 | $129.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.16 / $62.16 / $62.16
| Professional | | $62.16 | $62.16 | $62.16 |