- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.59 / $157.59 / $157.59
| Facility | | $157.59 | $157.59 | $157.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.53 / $157.59 / $157.59
| Professional | | $102.53 | $157.59 | $157.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.27 / $154.02 / $158.63
| Professional | | $124.27 | $154.02 | $158.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.18 / $158.57 / $352.34
| Professional | | $112.18 | $158.57 | $352.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.83 / $370.15 / $370.15
| Professional | | $157.83 | $370.15 | $370.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.45 / $144.53 / $424.11
| Professional | | $98.45 | $144.53 | $424.11 |