- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.38 / $135.38 / $135.38
| Facility | | $135.38 | $135.38 | $135.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.93 / $135.38 / $135.38
| Professional | | $100.93 | $135.38 | $135.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.42 / $236.42 / $243.60
| Facility | | $236.42 | $236.42 | $243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.42 / $236.42 / $236.42
| Professional | | $236.42 | $236.42 | $236.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.22 / $135.22 / $194.87
| Facility | | $135.22 | $135.22 | $194.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.72 / $135.22 / $190.30
| Professional | | $98.72 | $135.22 | $190.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.98 / $109.72 / $146.43
| Professional | | $71.98 | $109.72 | $146.43 |