- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.88 / $173.88 / $173.88
| Facility | | $173.88 | $173.88 | $173.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.31 / $133.46 / $173.88
| Professional | | $82.31 | $133.46 | $173.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.50 / $143.50 / $143.50
| Professional | | $143.50 | $143.50 | $143.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.33 / $138.33 / $217.73
| Facility | | $138.33 | $138.33 | $217.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.98 / $100.98 / $252.38
| Professional | | $100.98 | $100.98 | $252.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.12 / $96.19 / $144.88
| Professional | | $64.12 | $96.19 | $144.88 |