- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.32 / $146.56 / $188.10
| Facility | | $129.32 | $146.56 | $188.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.08 / $83.08 / $83.08
| Professional | | $83.08 | $83.08 | $83.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.10 / $188.10 / $188.10
| Professional | | $188.10 | $188.10 | $188.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.72 / $177.13 / $195.94
| Professional | | $147.72 | $177.13 | $195.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.43 / $188.10 / $219.45
| Professional | | $172.43 | $188.10 | $219.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.75 / $188.10 / $235.13
| Professional | | $156.75 | $188.10 | $235.13 |