- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.87 / $196.87 / $196.87
| Facility | | $196.87 | $196.87 | $196.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.07 / $196.87 / $303.98
| Professional | | $84.07 | $196.87 | $303.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.38 / $197.37 / $198.01
| Professional | | $174.38 | $197.37 | $198.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.10 / $300.94 / $461.65
| Professional | | $260.10 | $300.94 | $461.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.07 / $196.87 / $303.98
| Professional | | $84.07 | $196.87 | $303.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.44 / $280.33 / $404.72
| Professional | | $178.44 | $280.33 | $404.72 |