- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.88 / $156.88 / $156.88
| Facility | | $156.88 | $156.88 | $156.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.60 / $139.60 / $156.88
| Professional | | $139.60 | $139.60 | $156.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.38 / $404.21 / $496.55
| Facility | | $148.38 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.14 / $158.52 / $614.30
| Professional | | $123.14 | $158.52 | $614.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.31 / $149.79 / $267.18
| Professional | | $90.31 | $149.79 | $267.18 |