- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.47 / $128.47 / $128.47
| Facility | | $128.47 | $128.47 | $128.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.05 / $128.47 / $130.75
| Professional | | $118.05 | $128.47 | $130.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.32 / $154.32 / $254.63
| Professional | | $154.32 | $154.32 | $254.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.15 / $161.91 / $410.61
| Professional | | $108.15 | $161.91 | $410.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.22 / $150.76 / $307.06
| Professional | | $143.22 | $150.76 | $307.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.88 / $130.99 / $398.12
| Professional | | $107.88 | $130.99 | $398.12 |