- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.43 / $108.43 / $108.43
| Facility | | $108.43 | $108.43 | $108.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.33 / $108.43 / $108.43
| Professional | | $51.33 | $108.43 | $108.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.48 / $89.48 / $89.48
| Professional | | $89.48 | $89.48 | $89.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.43 / $73.43 / $122.36
| Facility | | $73.43 | $73.43 | $122.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.60 / $73.43 / $107.14
| Professional | | $53.60 | $73.43 | $107.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.08 / $58.63 / $88.31
| Professional | | $39.08 | $58.63 | $88.31 |