- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.72 / $132.72 / $132.72
| Facility | | $132.72 | $132.72 | $132.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.83 / $132.72 / $132.72
| Professional | | $62.83 | $132.72 | $132.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.03 / $87.03 / $87.03
| Professional | | $87.03 | $87.03 | $87.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.70 / $81.70 / $146.37
| Facility | | $81.70 | $81.70 | $146.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.64 / $81.70 / $128.16
| Professional | | $59.64 | $81.70 | $128.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.49 / $65.23 / $104.15
| Professional | | $43.49 | $65.23 | $104.15 |