- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.94 / $144.94 / $149.53
| Facility | | $144.94 | $144.94 | $149.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.01 / $144.94 / $168.48
| Professional | | $101.01 | $144.94 | $168.48 |
- 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
- $38.25 / $45.00 / $50.00
| Professional | | $38.25 | $45.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.73 / $342.87 / $445.73
| Professional | | $325.73 | $342.87 | $445.73 |