- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.67 / $117.67 / $187.54
| Facility | | $117.67 | $117.67 | $187.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.95 / $145.50 / $187.54
| Professional | | $115.95 | $145.50 | $187.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.72 / $162.72 / $162.72
| Facility | | $162.72 | $162.72 | $162.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.72 / $162.72 / $162.72
| Professional | | $162.72 | $162.72 | $162.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.66 / $139.66 / $139.66
| Facility | | $139.66 | $139.66 | $139.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $101.95 / $139.66
| Professional | | $101.95 | $101.95 | $139.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $100.09 / $161.41
| Professional | | $69.84 | $100.09 | $161.41 |