- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.46 / $144.46 / $144.46
| Facility | | $144.46 | $144.46 | $144.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.60 / $144.46 / $481.00
| Professional | | $115.60 | $144.46 | $481.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.88 / $199.28 / $308.02
| Professional | | $151.88 | $199.28 | $308.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.87 / $125.86 / $152.66
| Professional | | $95.87 | $125.86 | $152.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.45 / $308.92 / $464.07
| Professional | | $209.45 | $308.92 | $464.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.13 / $168.17 / $247.80
| Professional | | $126.13 | $168.17 | $247.80 |