- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.61 / $108.61 / $108.61
| Facility | | $108.61 | $108.61 | $108.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.42 / $108.61 / $108.61
| Professional | | $51.42 | $108.61 | $108.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.63 / $89.63 / $89.63
| Professional | | $89.63 | $89.63 | $89.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.33 / $84.33 / $119.70
| Facility | | $84.33 | $84.33 | $119.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.56 / $84.33 / $104.81
| Professional | | $61.56 | $84.33 | $104.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.90 / $56.85 / $90.77
| Professional | | $37.90 | $56.85 | $90.77 |