- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.47 / $131.47 / $131.47
| Facility | | $131.47 | $131.47 | $131.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.06 / $131.47 / $186.22
| Professional | | $123.06 | $131.47 | $186.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.09 / $224.76 / $275.97
| Professional | | $151.09 | $224.76 | $275.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.80 / $275.97 / $275.97
| Professional | | $189.80 | $275.97 | $275.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.64 / $230.78 / $678.65
| Professional | | $167.64 | $230.78 | $678.65 |