- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.27 / $161.27 / $161.27
| Facility | | $161.27 | $161.27 | $161.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.59 / $161.27 / $170.19
| Professional | | $141.59 | $161.27 | $170.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.67 / $188.67 / $188.67
| Professional | | $188.67 | $188.67 | $188.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.02 / $182.53 / $477.83
| Professional | | $146.02 | $182.53 | $477.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.43 / $337.20 / $504.40
| Professional | | $149.43 | $337.20 | $504.40 |