- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.15 / $151.15 / $151.15
| Facility | | $151.15 | $151.15 | $151.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.52 / $151.15 / $183.71
| Professional | | $141.52 | $151.15 | $183.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.12 / $134.30 / $351.17
| Professional | | $109.12 | $134.30 | $351.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.44 / $362.85 / $412.80
| Professional | | $161.44 | $362.85 | $412.80 |