- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.47 / $133.47 / $133.47
| Facility | | $133.47 | $133.47 | $133.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.76 / $102.71 / $133.47
| Professional | | $90.76 | $102.71 | $133.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.40 / $126.75 / $167.79
| Professional | | $95.40 | $126.75 | $167.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.52 / $134.52 / $134.52
| Professional | | $134.52 | $134.52 | $134.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.65 / $159.22 / $210.81
| Professional | | $104.65 | $159.22 | $210.81 |