- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.66 / $153.66 / $153.66
| Facility | | $153.66 | $153.66 | $153.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.66 / $154.47 / $200.81
| Professional | | $125.66 | $154.47 | $200.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.34 / $186.08 / $395.80
| Professional | | $151.34 | $186.08 | $395.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.34 / $325.58 / $395.80
| Professional | | $151.34 | $325.58 | $395.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.57 / $204.94 / $257.30
| Professional | | $143.57 | $204.94 | $257.30 |