- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.59 / $131.59 / $168.70
| Facility | | $131.59 | $131.59 | $168.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.52 / $160.26 / $190.16
| Professional | | $138.52 | $160.26 | $190.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.66 / $206.30 / $206.30
| Facility | | $198.66 | $206.30 | $206.30 |
- 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
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.13 / $186.27 / $249.50
| Professional | | $162.13 | $186.27 | $249.50 |