- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.36 / $190.36 / $190.36
| Facility | | $190.36 | $190.36 | $190.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.11 / $190.36 / $190.36
| Professional | | $90.11 | $190.36 | $190.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.10 / $157.10 / $157.10
| Professional | | $157.10 | $157.10 | $157.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.11 / $149.11 / $209.91
| Facility | | $149.11 | $149.11 | $209.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.85 / $149.11 / $183.81
| Professional | | $108.85 | $149.11 | $183.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.38 / $93.57 / $147.99
| Professional | | $62.38 | $93.57 | $147.99 |