- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.66 / $155.66 / $155.66
| Facility | | $155.66 | $155.66 | $155.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.09 / $155.66 / $163.77
| Professional | | $137.09 | $155.66 | $163.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.40 / $163.40 / $177.09
| Professional | | $163.40 | $163.40 | $177.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.66 / $155.66 / $155.66
| Facility | | $155.66 | $155.66 | $155.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.44 / $155.66 / $163.22
| Professional | | $140.44 | $155.66 | $163.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |