- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.55 / $176.55 / $176.55
| Facility | | $176.55 | $176.55 | $176.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.24 / $150.07 / $176.55
| Professional | | $141.24 | $150.07 | $176.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.21 / $151.83 / $217.12
| Facility | | $140.21 | $151.83 | $217.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.00 / $78.00 / $78.00
| Professional | | $78.00 | $78.00 | $78.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $136.80 / $191.52
| Professional | | $136.80 | $136.80 | $191.52 |