- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.55 / $197.55 / $361.64
| Facility | | $197.55 | $197.55 | $361.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.16 / $135.16 / $166.80
| Professional | | $135.16 | $135.16 | $166.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.15 / $142.15 / $142.15
| Professional | | $142.15 | $142.15 | $142.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.30 / $104.30 / $104.30
| Facility | | $104.30 | $104.30 | $104.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.00 / $183.65 / $349.92
| Professional | | $74.00 | $183.65 | $349.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.37 / $183.24 / $223.20
| Professional | | $109.37 | $183.24 | $223.20 |