- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.91 / $156.91 / $196.21
| Facility | | $156.91 | $156.91 | $196.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.91 / $155.29 / $216.70
| Professional | | $112.91 | $155.29 | $216.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.84 / $143.34 / $191.34
| Professional | | $121.84 | $143.34 | $191.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.32 / $184.33 / $344.25
| Professional | | $132.32 | $184.33 | $344.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.69 / $193.55 / $268.80
| Professional | | $159.69 | $193.55 | $268.80 |