- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.81 / $157.81 / $157.81
| Facility | | $157.81 | $157.81 | $157.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.34 / $148.57 / $157.81
| Professional | | $102.34 | $148.57 | $157.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.64 / $23.54 / $27.13
| Professional | | $17.64 | $23.54 | $27.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.34 / $199.34 / $211.07
| Professional | | $199.34 | $199.34 | $211.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.44 / $342.87 / $360.01
| Professional | | $315.44 | $342.87 | $360.01 |