- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.60 / $107.60 / $107.60
| Facility | | $107.60 | $107.60 | $107.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.50 / $36.50 / $107.60
| Professional | | $36.50 | $36.50 | $107.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.29 / $163.50 / $167.57
| Professional | | $138.29 | $163.50 | $167.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.25 / $132.56 / $166.69
| Professional | | $131.25 | $132.56 | $166.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.58 / $107.60 / $589.07
| Facility | | $52.58 | $107.60 | $589.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.11 / $62.76 / $117.83
| Professional | | $47.11 | $62.76 | $117.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.68 / $62.76 / $117.83
| Professional | | $37.68 | $62.76 | $117.83 |