- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.20 / $182.20 / $182.20
| Facility | | $182.20 | $182.20 | $182.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $182.20 / $182.20
| Professional | | $86.25 | $182.20 | $182.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.36 / $150.36 / $150.36
| Professional | | $150.36 | $150.36 | $150.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.63 / $132.63 / $187.01
| Facility | | $132.63 | $132.63 | $187.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.83 / $132.63 / $163.75
| Professional | | $96.83 | $132.63 | $163.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.39 / $83.92 / $121.83
| Professional | | $50.39 | $83.92 | $121.83 |