- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.06 / $140.06 / $140.06
| Facility | | $140.06 | $140.06 | $140.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.13 / $140.06 / $140.06
| Professional | | $71.13 | $140.06 | $140.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.02 / $124.02 / $124.02
| Professional | | $124.02 | $124.02 | $124.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.54 / $97.54 / $150.80
| Facility | | $97.54 | $97.54 | $150.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.20 / $97.54 / $132.05
| Professional | | $71.20 | $97.54 | $132.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.41 / $83.12 / $114.86
| Professional | | $48.41 | $83.12 | $114.86 |