- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.61 / $156.61 / $156.61
| Facility | | $156.61 | $156.61 | $156.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $156.61 / $156.61
| Professional | | $74.13 | $156.61 | $156.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.03 / $108.03 / $108.03
| Professional | | $108.03 | $108.03 | $108.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.24 / $104.24 / $172.72
| Facility | | $104.24 | $104.24 | $172.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.09 / $104.24 / $151.24
| Professional | | $76.09 | $104.24 | $151.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $76.97 / $124.06
| Professional | | $51.32 | $76.97 | $124.06 |