- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.61 / $117.61 / $187.44
| Facility | | $117.61 | $117.61 | $187.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.40 / $134.13 / $187.44
| Professional | | $110.40 | $134.13 | $187.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.62 / $162.62 / $162.62
| Facility | | $162.62 | $162.62 | $162.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.62 / $162.62 / $162.62
| Professional | | $162.62 | $162.62 | $162.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.05 / $147.05 / $147.05
| Facility | | $147.05 | $147.05 | $147.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.35 / $107.35 / $175.98
| Professional | | $107.35 | $107.35 | $175.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.40 / $99.62 / $156.28
| Professional | | $62.40 | $99.62 | $156.28 |