- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.52 / $147.52 / $147.52
| Facility | | $147.52 | $147.52 | $147.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.07 / $143.09 / $169.65
| Professional | | $115.07 | $143.09 | $169.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.00 / $292.00 / $344.56
| Professional | | $292.00 | $292.00 | $344.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.95 / $91.83 / $1,151.66
| Professional | | $63.95 | $91.83 | $1,151.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $147.52 / $221.28
| Professional | | $88.51 | $147.52 | $221.28 |